1. On or about the ____________ day of ________________, 19_____________, defendant issued a policy whereby the defendant insured the life of ___________________________________ who died on the _______ day of __________________ , 19____, of which the defendant has had notice.

2. As a result, the amount of the policy is now due and the plaintiff is the beneficiary of the proceeds of the policy.

Wherefore plaintiff demands judgment against defendant in the sum of _______________ dollars, interest and costs.