Insurance policy

Insurance policy. Company Code _________ Office Code _________ Policy Number _________ Name of Insured _________ Account Number _________ Agent _________ The undersigned, pursuant to the provisions, terms and conditions of the above policy number, make application to [Name of Insurance Company] of [City] [State] for a policy loan. I. [ ]To Pay Premiums As Shown Below: (Fill in information below for all premiums to be paid by loan.) Company Code Policy Numbers Premium Number Of Months To Be Paid Date Premium Is Due Amount Collected In Cash Cash Value To Be Applied $ II. [ ]Gross Cash Loan $_____ before making any deductions. [ ]Do not deduct the outstanding premium due. III. [ ]Loan To Net In Cash $_____ after making the deductions required by the policy. [ ]Do not deduct the outstanding premium due. The undersigned assign, transfer and set over to the Company the policy as sole security for the loan and interest. It is understood and agreed as follows: (1). The loan is made pursuant and subject to the provisions, terms and conditions of the policy. (2). The Company is directed and authorized to charge as an indebtedness against the policy the total of a) the loan granted under this agreement, including any unpaid premiums, and b) interest in advance if provided by the policy, and c) the existing loan, if any, including any unpaid interest. (3). The undersigned assignee, if any, in consideration of the loan, waives in favor of the Company whatever priority he or she might otherwise have. The undersigned certify that no assignment of the policy has been made and that no preceedings in bankruptcy have been instituted involving any of the undersigned, except as follows: _________. [ ]Mail check direct to payee. Signed at _________[Date]. _________ _________ Signature of Beneficiary or Assignee Signature of Insured/Owner/Controller When Applicable Address _________ AUTHORIZATION The undersigned authorize and direct [Name of Insurance Company] to issue its check in payment of the request made above to the sole order of _________ and doing so will be the Company's sufficient warrant and discharge. [Date] _________ _________ Signature of Beneficiary or Signature of Assignee Insured/Owner/Controller When Applicable Address _________