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This Declaration of Insurance Trust is made this _________(1)_______ day of _______
(2)_______, ________(3)________, by and between _________(4)__________, of __________
(5)_________, hereinafter called the Trustier, and _________(6)________, of _________(7)
__________, hereinafter called the Trustee.
The Trustier, as owner of certain life insurance policy or policies listed below, and
desiring to establish a Life Insurance Trust, with power in the Trustee upon the death of the
Trustier to purchase assets from Trustor's estate, assigns to the Trustee all his right, title, and
interest in the policy or policies of insurance, to be held by Trustee in trust, and to receive the
proceeds of the policy or policies of insurance when they become due and are paid, for the
purposes and on the conditions set forth herein. The Trustier reserves the right to add to this trust
from time to time additional life insurance policies which, when delivered to the Trustee, shall be
held by him subject to the terms herein.
(Description of Life Insurance policies)
The Trustee is vested with all right, title, and interest in the life insurance policy or
policies, and is authorized and empowered to exercise and enjoy, for the purposes of the trust
and as absolute owner of the policy of insurance, all the options, benefits, rights, and privileges
under the policy or policies. The Trustier relinquishes all rights and powers in the life insurance
policy or policies which are not assignable and will, at the request of the Trustee, execute all
other instruments reasonably required to effectuate this relinquishment. The trustee shall
receive and hold said Life Insurance policies, together with any additions thereto, in trust for the
use and benefit of:
(List names of Beneficiaries)
Upon the death of the Trustor, the Trustee may, within his discretion, purchase assets
from Trustor's estate at a fair value. The propriety of the purchase, the amount of such assets
purchased, and the ascertainment of fair value shall be solely within the discretion of the Trustee,
and the Trustee shall incur no liability as a result of the purchase or purchases whether or not the
assets constitute investments which may be legally made by Trustee.
If the Trustee uses all or any portion of the proceeds of the policy of insurance to
purchase assets from the estate of the Trustor, as authorized above, then the net income
produced from the assets, or the proceeds of any sale, exchange, or reinvestment of the assets,
shall be paid to the spouse of the Trustier during the spouse’s lifetime.
If any beneficiary of this trust who is at the time receiving income would otherwise, in the
opinion of the Trustee, be subject to hardship or suffering, the Trustee shall have the authority to
pay over and distribute, at any time and from time to time, to the beneficiary the amounts of the
principal of this trust, from which the beneficiary shall then be entitled to receive income as the
Trustee, in his sole discretion, shall deem necessary to provide for the maintenance, comfort,
support, and medical care of the beneficiary.
This Life Insurance Trust shall be irrevocable and UN-amendable. I am aware of the
consequences of establishing an irrevocable trust and hereby affirm that the trust created by this
agreement shall be irrevocable by me or any other person, it being my intention to make to the
beneficiary/beneficiaries named herein an absolute gift of the Life Insurance policies described in
paragraph I above.
This agreement and the trust created hereby shall be administered, managed, governed
and regulated in all respects according to applicable statutes of the State of _____(8)_____.
The Trustee, in addition to all other powers granted by this agreement and by law, shall
have the following additional powers with respect to the trust, to be exercised from time to time at
the Trustee's discretion:
Management of the Trust
To invest and reinvest, lease, rent, mortgage, insure, repair, improve or sell any of the
real and personal property of the trust as he may deem advisable.
Mortgages, Pledges and Deeds of Trust
To enforce any all mortgages, pledges and deeds of trust held by the trust and to
purchase at any sale thereunder any such real estate or personal property subject to any
mortgage, pledge of deed or trust.
To initiate or defend, at his discretion, any litigation affecting the trust.
Attorneys, Advisors and Agents
To employ and pay from the trust reasonable compensation to such attorneys,
accountants, brokers, and investment., tax and other advisors as he shall deem advisable.
Adjust of Claims
To submit to arbitration, to compromise or to release or otherwise adjust with or without
compensation, any and all claims affecting the trust estate.
No bond for the faithful performance of duties shall be required of any Trustee appointed
under this agreement.
The trustee shall receive reasonable compensation for the services performed by him,
but such compensation shall not exceed the amount customarily received by corporate fiduciaries
in the area for like services.
No Trustee of the trust created by this agreement shall at any time be held liable for any
action or default of himself, or of his agent, or of any other person in connection with the
administration and management of this trust unless caused by this own gross negligence or by
commission of a willful act of breach of trust.
The Trustee, by joining in the execution of this agreement, hereby signifies his
acceptance of this trust.
The Trustee shall have sole authority to determine what shall be defined as income and
what shall be defined as principal of the trust established by this agreement, and to determine
which costs, taxes and other expenses shall be paid out of income and which shall be paid of out
In the event that any portion of this agreement of the trust created hereby shall be held
illegal, invalid or otherwise inoperative, it is my intention that all of the other provisions hereof
shall continue to be fully effective and operative insofar as is possible and reasonable.
IN WITNESS WHEREOF, the parties hereto have executed this agreement the day and
year first above written.
__________(9)__________ __________(10)__________
__________(9)__________ __________(11)___________
STATE OF ___________(12)____________)
COUNTY OF __________(13)___________)
On this ________(14)________ day of ______(15)______, ________(16)_______,
before me personally came and appeared ______(17)______, known, and known to me, to be
the individuals described in and who executed the foregoing instrument, and who duly
acknowledged to me that he executed same for the purpose therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
My Commission Expires:______(19)_____

The information in this document is designed to provide an outline that you can follow
when formulating business or personal plans. Due to the variances of many local, city, county
and state laws, we recommend that you seek professional legal counseling before entering into
any contract or agreement.