Policy Loan Agreement

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POLICY LOAN AGREEMENT
IN CONSIDERATION Of the sum of
Dollars advanced
by INVESTORS HERITAGE LIFE INSURANCE COMPANY, FRANKFORT, KY., as a LOAN on the sole
security of and in accordance with the Policy Loans provision contained In Policy Number
on the life of
issued or assumed by the said Company, I (we) hereby assign said policy and all sums of money now due or hereafter to
become due thereunder, to said Company as security for repayment of the said loan and interest thereon. Interest shall be
payable at the rate and at the times and in the manner provided in the policy. It is agreed that any interest which is not paid
when due shall be added to the principal of the loan, shall become a part thereof and shall bear interest at the same rate and
on the same conditions as the loan.
It is also agreed that the principal of the said loan with any interest due and accrued thereon shall become due and
payable whenever the insurance under the said policy shall become due and payable, or whenever the total indebtedness on
the said policy shall equal or exceed the cash value of the said policy, or when any premium on the said policy shall not be
paid when due. If at any time the entire indebtedness evidenced by this loan, together with any other indebtedness on said
policy, shall equal or exceed the cash value of the policy, the Company’s liability under the policy shall terminate upon
compliance by the Company with the requirements of law and the policy, if any, respecting notice.
If the said policy shall lapse or become forfeited in any manner, the amount of the said loan with interest accumu-
lated or accrued thereon (1) shall be deducted from any cash value of said policy; or (2) shall operate to reduce the amount
of any Paid-up insurance or to reduce the amount of and/or the term of any Extended Term Insurance in the manner pro-
vided by the terms of the said Policy.
It is expressly represented that all natural persons signing below are of legal age and that no proceedings in bank-
ruptcy or insolvency have been instituted or are pending against any of the undersigned.
IN WITNESS WHEREOF, the undersigned have executed this agreement
this
day of
,
DAY
MONTH
YEAR
Complete required Policy Owner’s information below:
Check if new address
O
S
S
N
:
WNER
S
OCIAL
ECURITY
UMBER
S
:
TREET ADDRESS
C
:
S
:
Z
C
:
ITY
TATE
IP
ODE
(
)
Owner-Day time phone:
Home
Cell
Work
Owner‘s email address
X
X
Owner’s Name (printed)
Owner’s Signature
Subscribed and sworn before me this ____ day of ___________, _____.
State of: ____________________
County of: ___________________
My commission expires on__________________
___________________________________
Notary Public
Form 52 (1-65) Revised 02/2009

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