In consideration of the sum of xxxx Thousand Dollars
($xx,xxx) paid to ____________, the cheque for which to be sent
to the undersigned by those Underwriters at Lloyd's, London,
subscribing to Policy No. xxxxxxx, the receipt of which is hereby
acknowledged, the undersigned hereby remises, releases and
forever discharges those said Underwriters at Lloyd's, London, of
and from all debts, demands, actions, causes of action, suits,
accounts, contracts, agreements, damages, claims for attorney
fees under any statute whatsoever, claims under any statute or in
law or equity with respect to the adjustment or settlement of
this claim, and any and all claims, demands, and liabilities
whatsoever of every name and nature, both in law and equity,
which against those said Underwriters at Lloyd's, London, or
their heirs and assigns, the undersigned now has or ever had from
the beginning of the world to this date and more especially on
account of any and all claims under said Policy No. xxxxxxx and
any and all other policies, arising out of an injury which
occurred on or about ______________, and which injury has
resulted in the permanent total disablement of _____________ to
perform as a professional hockey player.

         In further consideration of the above payment, the
undersigned agrees that prior to delivering the said cheque to
_______________, the National Hockey League Players' Association
will obtain from such player a release of the said player's
claims against the National Hockey League Players' Association,
and the Underwriters and will cause such player to execute an
Undertaking wherein the player agrees to refund such payment in
the event he shall return to professional hockey.

         Dated this ____________ day of ________________ A.D.
19__.

Signed, sealed and delivered in the presence of           
National Hockey League Player's Association


                              By                                 
                              Its Executive Director

CANADA

PROVINCE OF ONTARIO

          On this _____ day of _____________, A.D. 19__, before
me, ___________, the undersigned officer, personally appeared
Robert W. Goodenow, who acknowledged himself to be the Executive
Director of the National Hockey League Players' Association, and
that he, as such Executive Director, being authorized so to do,
executed the foregoing instrument for the purposes therein
contained, by signing the name of the National Hockey League
Players' Association by himself as Executive Director.

          IN WITNESS WHEREOF, I hereunto set my hand and official
seal.
                                                                 
                              Notary Public
                              My Commission Expires:

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