Pledge of Life Insurance Policy to a Creditor

______________, referred to as DEBTOR, and __________, referred to as CREDITOR, agree:

______________ is indebted to CREDITOR in the amount of $_____(_________________________&___/100 dollars) by virtue of _________________ 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.

Dated: _________________________

____________________________________________

Debtor

Insurance Policy Number:

_____________________________________________

___________________, by an authorized officer of Creditor

Pledge of Life Insurance Policy to a Creditor

Review List

This review list is provided to inform you about this document in question and assist you in its preparation. A pledge of life insurance proceeds is a common request by major creditors including financial institutions buying stock from the Company. It secures their interest should a key principal die.