______________, referred to as DEBTOR, and __________, referred to as CREDITOR, agree:
______________ is indebted to CREDITOR in the amount of $______ (_____________________&___/100 dollars) by the terms of the agreement named _________________, dated ____________. DEBTOR assigns to CREDITOR the following policy of life insurance:
Policy number: __________________________________________________
Face amount: $___________(_______________________&____/100 dollars)
Amount of loans/charges against policy: $___________(_____________ __________&____/100 dollars) as collateral for the debt.
Any and all proceeds from the policy are assigned to the CREDITOR, to the extent of principal and interest due upon the debt, and any renewals and extensions thereof. The DEBTOR shall prepare any further instruments required to effect this pledge. Any proceeds that exceed the above obligations shall be immediately turned over to the Estate of Debtor.