A B, being the holder of policy numbered in the books of the [here set out name of company], (subject, however, to [here state prior mortgages, if any]), insuring $ on the life of , in consideration of the sum of $ this day lent and advanced to him by E F, of [or, if consideration not an advance of money, here state the consideration for which mortgage given], doth hereby, for himself, his executors, administrators, and assigns, all hereinafter, and also in the covenants, powers, and agreements implied herein by the Life Insurance Act 1908, referred to as and included in the term
“mortgagor,” covenant with the said E F, his executors, administrators, and assigns, all hereinafter, and also in the said implied covenants, powers, and agreements, referred to as
“the mortgagee,” that he will repay the said principal sum of $ on the day of 19 , together with interest thereon or on so much thereof as for the time being remains unpaid, in the meantime and until repaid, at the rate of $ percent per annum, payable by payments on the day of the months of in each year [or, if mortgage not given to secure a loan, strike out previous covenants, and here set out covenant to perform the obligation for the securing of which mortgage is given]. [Here set out special covenants, if any]; and, for the better securing to the mortgagee the performance of the covenants herein set forth, the mortgagor hereby mortgages to the mortgagee all his right, title, and interest in the said policy above described.
In witness whereof the mortgagor has hereunto subscribed his name this day of 19 .
Signed by the above-named A B, as mortgagor, in the presence of—
[Occupation and address.]