Exhibit 10.42

 

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Assignment Of Life Insurance Policy as Collateral

 

 

 

INSTRUCTIONS:

 

Use this form to assign a policy(ies) as collateral for a loan. By completing
this form, the Owner will transfer certain ownership rights as outlined in
Section III, B to the Collateral Assignee.

 

Please complete this form in its entirety to avoid any delays in processing. If
you need assistance in completing this form, please call your representative,
sales office, or the appropriate number listed under How to Submit this Form.

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The Company indicated in this section is referred to as “the Company.”   

x  Metropolitan Life Insurance Company

 

¨  New England Life Insurance Company

 

¨  General American Life Insurance Company

 

¨  MetLife Insurance Company of Connecticut

  

¨  First MetLife Investors Insurance Company

 

¨  MetLife Investors USA Insurance Company

 

¨  MetLife Investors Insurance Company

 

¨  Metropolitan Tower Life Insurance Company

Policy Number(s) 213017769MLU             ,                        
                 ,                                         

 

SECTION I - About the Insured           First Name    Middle Name    Last Name

Carl

  

A

  

Grimstad

 

SECTION II - About the Collateral Assignee Name of Assignee    Tax ID of
Assignee

iPayment, Inc.

  

62-1847043

 

Number and Street/Post Office Box

Tower 56, 126 East 56th Street, 33rd Floor

 

City    State    Zip    E-Mail Address

New York

  

NY

  

10022

  

 

 

If Assignee is a Trust, list name(s) of all currently serving trustees: First
Name    Middle Name    Last Name

 

  

 

  

 

First Name    Middle Name    Last Name

 

  

 

  

 

First Name    Middle Name    Last Name

 

  

 

  

 

 

 

 

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SECTION III - Terms of the Assignment

 

A. For Value Received the undersigned hereby assign, transfer and set over to
the above Assignee, its successors and assigns (herein called the “Assignee”),
the above Policies issued by the Company and any supplementary contracts issued
in connection therewith (said policy and contracts being herein called the
“Policy”), upon the life of the above Insured and all claims, option,
privileges, rights, title and interest therein and thereunder (except as
provided in Paragraph C hereof), subject to all the terms and conditions of the
Policy and to all superior liens, if any, which the Company may have against the
Policy. The undersigned by this instrument jointly and severally agree and the
Assignee by the acceptance of this assignment agrees to the conditions and
provisions herein set forth.

B. It is expressly agreed that, without detracting from the generality of the
foregoing, the following specific rights are included in this assignment and
pass by virtue hereof:

 

  1. The sole right to collect from the Company the net proceeds of the Policy
when it becomes a claim by death or maturity;

 

  2. The sole right to surrender the Policy and receive the surrender value
thereof at any time provided by the terms of the Policy and at such other times
as the Company may allow;

 

  3. The sole right to obtain one or more loans or advances on the Policy,
either from the Company or, at any time from other persons, and to pledge or
assign the Policy as security for such loans or advances;

 

  4. The sole right to collect and receive all distributions or shares of
surplus, dividend deposits or additions to the Policy now or hereafter made or
apportioned thereto, and to exercise any and all options contained in the Policy
with respect thereto; provided, that unless and until the Assignee shall notify
the Company in writing to the contrary, the distributions or shares of surplus,
dividend deposits and additions shall continue on the plan in force at the time
of this assignment; and

 

  5. The sole right to exercise all nonforfeiture rights permitted by the terms
of the Policy or allowed by the Company and to receive all benefits and
advantages derived therefrom.

C. It is expressly agreed that the following specific rights, so long as the
Policy has not been surrendered, are reserved and excluded from this assignment
and do not pass by virtue hereof:

 

  1. The right to collect from the Company any disability benefit payable in
cash that does not reduce the amount of insurance;

 

  2. The right to designate and change the beneficiary; and

 

  3. The right to elect any optional mode of settlement permitted by the Policy
or allowed by the Company; but the reservation of these rights shall in no way
impair the right of the Assignee to surrender the Policy completely with all its
incidents or impair any other right of the Assignee hereunder, and any
designation or change of beneficiary or election of a mode of settlement shall
be made subject to this assignment and to the rights of the Assignee hereunder.

D. This assignment is made and the Policy is to be held as collateral security
for any and all liabilities of the undersigned, or any of them, to the Assignee,
either now existing or that may hereafter arise between any of the undersigned
and the Assignee with respect to the above Policy (all of which liabilities
secured or to become secured are herein called “Liabilities”).

E. The Assignee covenants and agrees with the undersigned as follows:

 

  1. That any balance of sums received hereunder from the Company remaining
after payment of the then existing Liabilities, matured or unmatured, shall be
paid by the Assignee to the persons entitled thereto under the terms of the
Policy had this assignment not been executed;

 

  2. That the Assignee will not exercise either the right to surrender the
Policy or (except for the purpose of paying premiums) the right to obtain policy
loans from the Company, until there has been default in any of the Liabilities
or a failure to pay any premiums when due, nor until twenty days after the
Assignee shall have mailed, by first-class mail, to the undersigned at the
addresses last supplied in writing to the Assignee specifically referring to
this assignment, notice of intention to exercise such right; and

 

  3. That the Assignee will upon request forward without unreasonable delay to
the Company the Policy for endorsement of any designation or change of
beneficiary or any election of an optional mode of settlement.

F. The Company is hereby authorized to recognize the Assignee’s claims to the
rights hereunder without investigation the reason for any action taken by the
Assignee, or the validity of the amount of the Liabilities or the existence of
any default therein, or the giving of any notice under Paragraph E (2) above or
otherwise, or the application to be made by the Assignee of any amounts to be
paid to the Assignee. The sole signature of the Assignee shall be sufficient of
the exercise of any rights under the Policy assigned hereby and the sole receipt
of the Assignee for any sums received shall be a full discharge and release
therefore to the Company. Checks for all or any part of the sums payable under
the Policy and assigned herein, shall be drawn to the exclusive order of the
Assignee if, when, and in such amounts as may be, requested by the Assignee.

G. The Assignee shall be under no obligation to pay any premium, or the
principal of or interest on any loans or advance on the Policy whether or not
obtained by the Assignee, or any other charges on the Policy, but any such
amounts so paid by the Assignee from its own funds, shall become a part of the
Liabilities hereby secured, shall be due immediately, and shall draw interest at
the annual percentage rate then in effect for the note or other evidence of
liability.

 

 

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H. The exercise of any right, option, privilege or power given herein to the
Assignee shall be at the option of the Assignee, but (except as restricted by
Paragraph E (2) above) the Assignee may exercise any such right, option,
privilege or power without notice to, or assent by, or affecting the liability
of, or releasing any interest hereby assigned by the undersigned, or any of
them.

I. The Assignee may take or release other security, may release any party
primarily or secondarily liable for any of the Liabilities, may grant
extensions, renewals or indulgences with respect to the Liabilities, or may
apply to the Liabilities in such order as the Assignee shall determine, the
proceeds of the Policy hereby assigned or any amount received on account of the
Policy by the exercise of any right permitted under this assignment, without
resorting or regard to other security.

J. In the event of any conflict between the provisions of this assignment and
provisions of the note or other evidence of any Liability, with respect to the
Policy or rights of collateral security therein, the provisions of this
assignment shall prevail.

K. Each of the undersigned declares that no proceedings in bankruptcy are
pending against him and that his property is not subject to any assignment for
the benefit of creditors.

Signatures

 

All Owners are required to sign this form. Any Irrevocable Beneficiary must sign
this form.

Please sign as shown below:

 

A Partnership    The signature and title of one authorized partner (other than
the Insured). A Sole Proprietorship    The full name of the business should be
printed with the signature of the owner followed by the word “sole owner.” A
Trust    Signatures, followed by the word “Trustee,” of all required Trustees.
Also submit a Trust Certification, which is available from your representative,
sales office, or the appropriate number listed under How to Submit this Form. A
Corporation    The signature and title of one officer (other than the Insured).
An Individual acting on behalf of the Owner    The full name of the Owner’s
fiduciary or agent and the legal documentation of the authority to act (e.g.,
power of attorney, guardianship papers, etc.).

 

Type of Owner:    ¨  Individual    x  Trust    ¨ Corporation or Partnership   

Tax ID or Social Security Number

###-##-####

 

Name of Trust, Corporation or Partnership

The Carl A Grimstad 2013 Insurance Trust I

  

Date of Trust 1/25/2013

 

u  

Signature

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Date

3/4/13

  

Title (If you are acting in a representative capacity)

Trustee

 

 

  

 

  

 

  Printed Name - First    Middle          Last  

J. Daniel

  

 

  

Schmidt

u  

Signature of Witness

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Date

 

3/4/13

 

 

  

 

  Printed Name - First    Middle          Last   LOGO [g492058g01j98.jpg]     
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Number and Street/Post Office Box of Owner

Tower 56, 126 East 56th Street, 33rd Floor

                         City          State    Zip    E-Mail Address

New York

  

NY

  

10022

  

 

 

 

 

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Type of Co-Owner: ¨ Individual  ¨ Trust    ¨ Corporation or Partnership   

Tax ID or Social Security Number

    

Name of Trust, Corporation or Partnership

    

       

Date of Trust

 

 

  Signature of Co-Owner       Date    Title (If you are acting in a
representative capacity) u  

 

  

 

  

 

  Printed Name - First    Middle       Last  

 

  

 

  

 

  Signature of Witness          Date u  

 

                          Printed Name - First    Middle       Last  

 

  

 

  

 

 

Beneficiary’s signature is necessary only if beneficiary is irrevocably
designated or if required by assignee.

 

Type of Beneficiary:    ¨ Individual x Trust        ¨ Corporation or Partnership

 

Name of Trust, Corporation or Partnership

 

The Carl A Grimstad 2013 Insurance Trust I

  

Date of Trust

1/25/2013

 

u  

Signature of Beneficiary

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Date

 

3/4/13

  

Title (if you are acting in a representative capacity)

 

Trustee

 

 

  

 

  

 

  Printed Name - First    Middle       Last  

J Daniel

  

 

  

Scmidt

  Signature of Witness          Date u  

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3/4/13

  Printed Name - First    Middle       Last   LOGO [g492058g01j98.jpg]        
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Type of Beneficiary:     ¨ Individual     ¨ Trust         ¨ Corporation or
Partnership

 

Name of Trust, Corporation or Partnership

   Date of Trust

 

  

 

 

  Signature of Beneficiary       Date    Title (If you are acting in a
representative capacity) u  

 

  

 

  

 

  Printed Name - First    Middle       Last     

 

  

 

  

 

  Signature of Witness          Date    u  

 

  

 

     Printed Name - First    Middle       Last     

 

  

 

  

 

 

 

 

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