Loan to insured to be repaid only from recovery from third person for loss covered. Date _________ Amount _________ Make and Model _________ Loan Motor No. _________ Serial No. _________ Receipt Received from the _________ company (referred to as company) the amount shown above as a loan, without interest, repayable only in the event and to the extent of any net recovery the undersigned may make from any person, persons, corporation or corporations, or other parties, causing or liable for the loss or damage to the property described above, or from any insurance effected on such property, and as security for such repayment the undersigned pledges to the company all claims against that person, persons, corporation or corporations or other parties, or from any insurance carrier or carriers, and any recovery on them, and delivers to company all documents necessary to show interest in the property. The undersigned covenants that no settlement has been made by the undersigned with any person, persons, corporation or corporations, or other parties against whom a claim may lie, and that no release has been given to anyone responsible for such loss, and that no such settlement will be made, nor release given without the written consent of the company. The undersigned agrees to promptly present claim and, if necessary, to commence, enter into and prosecute suit against such person or persons, corporation or corporations, or other parties, through whose negligence or other fault the loss was caused, or who may otherwise be responsible for it, with all due diligence, in his or her, its or their own name. In further consideration of the advance the undersigned guarantee(s) that he, she, it or they are the owner(s) of the property and entitled to recover upon the claim for loss or damage to it. And appoint(s) the managers and/or agents of the company and their successors severally, his, her, its or their agent(s) and attorney(s)-in-fact, with irrevocable power, to collect any such claim or claims, and to begin, prosecute, compromise or withdraw in his, her, its or their name, but at the expense of the company any and all legal proceedings that the company may deem necessary to enforce such claim or claims, and to execute in the name of the undersigned, any documents that may be necessary to carry the same into effect for the purposes of this agreement. Any legal proceedings are to be under the exclusive direction and control of company. The property set forth above is as follows: _________. Witness our hand the date above written. Witness: _________ By _________[Officer] Request To Employ Counsel The undersigned, having suffered a property loss of $_____ in excess of the $_____ named in the foregoing loan receipt, requests the insurance company to employ counsel for and on my behalf, to effect recovery of it, only, however, in the event that insurance company employs counsel on its own behalf. It is agreed, that, in event of recovery the net proceeds of recovery (after payment of costs and attorneys' fees) shall be apportioned between the undersigned and the insurance company as the interest of each appears in this agreement. Witness: _________