_________[Date]

For value received payor promises to pay to the order of payee $_____ at _________, payable _________[state terms of payment of principal and interest].

To secure payment of the full amount owing by payor under this note, payor assigns to payee, his or her [its] heirs [etc.] all return or unearned premiums, all dividends and all losses which are or may become payable to payor under the insurance policies set forth below (or any policies issued in substitution for them and the policies are delivered to payee by this means.

In the event of default in the payment of any installment of this note, the unpaid balance shall become immediately due and payable, and payor agrees that such default shall be construed as and shall be notice to cancel the policies of insurance and the payee or payee's assignees may deliver the policies to the insurance company issuing them for cancellation and receive any and all return premiums on them and receipt for them in the name of payor.

Payor does irrevocably appoint payee, or in the event this note is held by the _________ bank, the bank, his or her attorney-in-fact to effect cancellation of the policies, as well as to collect any moneys payable for any reason under the policies, to give receipt, release and acquittance for them, and to do everything necessary in connection with that, with full power of substitution, ratifying and confirming by this means all that such attorney-in-fact, or its substitute may lawful do under this agreement.