Exhibit 10.11

FIDELITY BANK

SPLIT DOLLAR LIFE INSURANCE AGREEMENT

Economic Benefit Regime – Endorsement Method

THIS SPLIT DOLLAR LIFE INSURANCE AGREEMENT (the “Agreement”) is made and entered
into this _________ day of _______________, by and between Fidelity Bank (the
“Bank”), a banking corporation organized and existing under the laws of the
State of Georgia, and ______________ (the "Insured").

WITNESSETH:

WHEREAS, the Insured is employed by the Bank; and
    
WHEREAS, the Bank highly values the efforts, abilities, and accomplishments of
the Insured and, as an inducement for the Insured’s continued employment, wishes
to assist the Insured with his personal insurance program; and
    
WHEREAS, the Bank has determined that this assistance can best be provided under
a "split-dollar" arrangement as defined in Treasury Regulations
§1.61-22(b)(1)&(2); and
    
WHEREAS, the Bank wishes to provide life insurance protection for the Insured’s
family in the event of the Insured’s death, under policies of life insurance
insuring the life of the Insured (the “Policy” or the “Policies”), which are
described in Exhibit A attached hereto, (the “Insurer” or “Insurers”); with such
additions and deletions as may be made from time to time by amendments to
Exhibit A; and

WHEREAS, the Bank is willing to pay the premiums due on the Policies as an
additional employment benefit for the Insured, on the terms and conditions
hereinafter set forth; and

WHEREAS, the Bank is the sole owner of the Policies and elects to endorse a
portion of the death benefit of the Policies to the Insured.

NOW, THEREFORE, in consideration of the mutual undertakings set forth in this
Agreement, and for other good and valuable consideration, the receipt and
sufficiency of which are hereby acknowledged, the Bank and the Insured agree as
follows:

ARTICLE I
“Definitions”

1.1    Refer to Policy contracts for the definitions of any terms in this
Agreement that are not defined herein. If the definition of a term in a Policy
is inconsistent with the definition of a term in this Agreement, then the
definition of the term as set forth in this Agreement shall supersede and
replace the definition of the terms as set forth in the Policy.

ARTICLE II
"Purchase of Policies"

2.1    The parties hereto have taken or will take all necessary action to cause
the Insurers to issue the Policies, and shall take any further action which may
be necessary to cause the Policies to conform to the provisions of this
Agreement. The parties hereto agree that the Policies shall be subject to the
terms and conditions of this Agreement and of the endorsement to the Policies
filed with the Insurers.

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Exhibit 10.11

ARTICLE III
"Policy Title and Ownership"

3.1    Title and ownership of the Policies shall reside in the Bank for its use
and for the use of the Insured, all in accordance with this Agreement. The Bank
alone may, to the extent of its interest, exercise the right to borrow or
withdraw on the Policy cash values. Where the Bank and the Insured (or assignee,
with the consent of the Insured) mutually agree to exercise the right to
increase the coverage under the subject Policy, then, in such event, the rights,
duties and benefits of the parties to such increased coverage shall continue to
be subject to the terms of this Agreement.

3.2    The Bank, at its sole discretion, shall have the right to determine the
face amount of each Policy purchased on the Insured and shall have the right to
determine whether the Policies are term, universal or whole life.

ARTICLE IV
“Beneficiary”

4.1    Beneficiary Designation. The Insured shall have the right and power to
designate a beneficiary or beneficiaries to receive the Insured’s share of the
proceeds payable upon the death of the Insured and to elect and change a payment
option for such beneficiary, subject to any right or interest the Bank may have
in such proceeds, as provided in this Agreement. The Insured shall have the
right to name such beneficiary at any time prior to the Insured’s death and
submit it to the Plan Administrator (or Plan Administrator’s representative) on
the written form provided. The Insured’s beneficiary designation shall be deemed
automatically revoked if the Insured names a spouse as beneficiary and the
marriage is subsequently dissolved.

4.2    Beneficiary Acknowledgement. Once received and acknowledged by the Plan
Administrator, the form shall be effective. The Insured may change a beneficiary
designation at any time by submitting a new form to the Plan Administrator. Any
such change shall follow the same rules as for the original beneficiary
designation and shall automatically supersede the existing beneficiary form on
file with the Plan Administrator. Upon the acceptance by the Bank of a new
beneficiary form, all previously filed beneficiary forms shall be cancelled. The
Bank shall be entitled to rely on the last beneficiary form filed by the Insured
and accepted by the Bank prior to the Insured’s death.

4.3    No Beneficiary Designation. If the Insured dies without a valid
beneficiary designation on file with the Plan Administrator, or if all
designated beneficiaries predecease the Insured, then the Insured’s surviving
spouse shall be the designated beneficiary. If the Insured has no surviving
spouse, the benefits shall be made payable to the Insured’s estate.

4.4    Facility of Payment. If the Plan Administrator determines in its
discretion that a benefit is to be paid to a minor, to a person declared
incompetent, or to a person incapable of handling the disposition of that
person’s property, the Plan Administrator may direct distribution of such
benefit to the guardian, legal representative or person having the care or
custody of such minor, incompetent person or incapable person. The Plan
Administrator may require proof of incompetence, minority or guardianship as it
may deem appropriate prior to distribution of the benefit. Any distribution of a
benefit shall be a distribution for the account of the Insured and the
beneficiary, as the case may be, and shall be a complete discharge of any
liability under the Agreement for such distribution amount.

ARTICLE V
"Premium Payment and Taxable Benefit"

5.1     Premium Payment. The Bank shall pay an amount equal to the planned
premiums and any other premium payments that might become necessary to keep the
Policies in force as determined by the Insurers. Notwithstanding the forgoing,
the Bank shall have the absolute and sole right to terminate or surrender the
Policies.

5.2    Taxable Benefit. The Bank shall determine the economic benefit
attributable to the Insured based on the life insurance premium factor for the
Insured’s age multiplied by the amount of current life insurance protection

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Exhibit 10.11

payable to the Insured’s beneficiary. The “life insurance premium factor” is the
minimum amount required to be imputed under Treasury Regulation
§1.61-22(d)(3)(ii) or any subsequent applicable authority.

5.3    Imputed Income. The Bank shall impute the economic benefit to the Insured
on an annual basis, by adding the economic benefit to the Insured’s W-2, or if
applicable, Form 1099.

ARTICLE VI
"Ownership of the Cash Surrender Value of the Policies"

6.1    The Bank shall at all times be entitled to one hundred percent (100%) of
each Policy’s cash value, as that term is defined in the Policy contract, less
any Policy loans and unpaid interest or cash withdrawals previously incurred by
the Bank. Such cash value shall be determined as of the date of surrender or
death as the case may be.

ARTICLE VII
"Rights of Insured or Assignees"
7.1    The Insured may not, without the written consent of the Bank, assign to
any individual, trust or other organization, any right, title or interest in the
subject Policies nor any rights, options, privileges or duties created under
this Agreement, other than the right to name a beneficiary(ies) from time to
time.

ARTICLE VIII
"Limitations on Bank’s Rights in Policies"
8.1    Notwithstanding any provision hereof to the contrary, the Bank shall have
the right to sell or surrender a Policy without terminating this Agreement,
provided (i) the Bank replaces the Policy with a comparable life insurance
policy or arrangement that provides the benefit provided under this Agreement
and (ii) the Bank and the Insured (who will not unreasonably withhold his
signature) execute a new Policy endorsement for said comparable coverage
arrangement, at which time all references to “Policy” hereunder shall refer to
such replacement coverage arrangement. Without limitation, the Policies at all
times shall be the exclusive property of the Bank and shall be subject to the
claims of the Bank’s creditors.

ARTICLE IX
"Policy Loans"

9.1    The Bank may pledge or assign the Policies, subject to the terms and
conditions of this Agreement, for the sole purpose of securing a loan from the
Insurer or from a third party. Interest charges on such loan shall be paid by
the Bank. If the Bank so encumbers the Policies, other than by a Policy loan
from the Insurer, then, upon the death of the Insured, the Bank shall promptly
take all action necessary to secure the release or discharge of such
encumbrance.

ARTICLE X
"Division of Death Proceeds"

10.1    Insured’s Death Benefit. The Insured’s Death Benefit shall mean, upon
the death of the Insured while this Agreement is in force, the Insured’s
beneficiary shall be entitled to an amount of aggregate Policy death proceeds
equal to the accrued liability at retirement from the Supplemental Executive
Retirement Plan limited to one hundred percent (100%) of the Net Amount at Risk
insurance portion of the proceeds. For purposes of this Agreement, “Net Amount
at Risk” will mean the difference between the total death proceeds payable under
the Policies less the aggregate cash value of the Policies measured as of the
date giving rise to the need for such calculation. The receipt of this amount by
the beneficiary shall constitute satisfaction of the Insured’s rights under this
Agreement.

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Exhibit 10.11

10.2    Bank’s Benefit. Upon the death of the Insured, the Bank shall be
entitled to receive the remainder of the aggregate Policy death proceeds not
payable under Section 10.1 above.

10.3    Benefit Paid by Insurer. The benefit payable to the Insured’s
beneficiary shall be paid solely by the Insurer from the proceeds of the
Policies on the life of the Insured. In no event shall the Bank be obligated to
pay a death benefit under this Agreement from its general funds. Should an
Insurer refuse or be unable to pay death proceeds endorsed to Insured under the
express terms of this Agreement, or should the Bank cancel the Policies for any
reason, neither the Insured nor any beneficiary shall be entitled to a death
benefit.

10.4    Suicide or Misstatement. The amount of the benefit payable to the
Insured’s beneficiary may be reduced or eliminated if Insured fails or refuses
to take a physical examination, to truthfully and completely supply such
information or complete any forms as may be required by the Bank or Insurer, or
otherwise fails to cooperate with the requests of the Bank or the Insurer, or if
the Insured dies under circumstances such that a Policy does not pay a full
death benefit, e.g., in the case of suicide within the exclusionary period of
the Policy; provided, however the Bank shall evaluate the reason for the denial,
and upon advice of legal counsel and in its sole discretion, consider judicially
challenging any denial.

ARTICLE XI
"Termination of the Agreement”

11.1    This Agreement shall terminate upon the occurrence of any one of the
following:
(1) The total cessation of the business of the Bank;
(2) The bankruptcy, receivership or dissolution of the Bank;
(3) The termination of the Insured’s employment;
(4) While the Insured is living by written notice thereof by either the Bank or
the Insured to the other;
(5) Surrender, lapse, or other termination of the Policies by the Bank; or
(6) Upon distribution of the death benefit proceeds in accordance with Article
X.

Upon the termination of this Agreement, the Bank may make such disposition of
the Policies as it determines to be appropriate. Insured will have no rights in
such Policies or the death benefit proceeds thereof, if this Agreement is
terminated.
ARTICLE XII
"Insurer Not a Party”

12.1    The Insurers shall be fully discharged from their obligations under the
Policies by payment of the Policy death benefits to the beneficiary or
beneficiaries named in the Policies, subject to the terms and conditions of the
Policies. In no event shall an Insurer be considered a party to this Agreement,
or any modification or amendment hereof, and none of the provisions herein shall
in any way be construed as enlarging, changing, varying or in any other way
affecting the obligations of the Insurer as expressly provided in the Policies,
except insofar as the provisions hereof are made a part of the Policies by the
beneficiary designation executed by the Bank and filed with the Insurer in
connection herewith.

ARTICLE XIII
"Administration”

13.1    Plan Administrator. This Agreement shall be administered by the Bank’s
board of directors or any subset of the board at the pleasure of its Chairman
(the “Plan Administrator”).
    
13.2    Plan Administrator Duties. The Plan Administrator shall have the
discretion and authority to: (i) make, amend, interpret and enforce all
appropriate rules and regulations for the administration of this Agreement and
(ii) decide or resolve any and all questions, including interpretations of this
Agreement, as may arise in connection with this Agreement.

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Exhibit 10.11

13.3    Binding Effect of Decisions. Any decision or action of the Plan
Administrator with respect to any question arising out of or in connection with
the administration, interpretation, and application of this Agreement and the
rules and regulations promulgated hereunder shall be final and conclusive and
binding upon all persons having any interest in this Agreement.

13.4    Indemnity of Plan Administrator. The Bank shall indemnify and hold
harmless the members of the Plan Administrator, and those to whom management and
operation responsibilities of the plan have been delegated, against any and all
claims, losses, damages, expenses or liabilities arising from any action or
failure to act with respect to this Agreement, except in the case of willful
misconduct by the Plan Administrator or any of its members.

ARTICLE XIV
"Claims and Review Procedures”

14.1    Written Claim. A person who believes that he or she is being denied a
benefit to which he or she is entitled under this Agreement (“Claimant”) may
file a written request for such benefit with the Plan Administrator, setting
forth his or her claim. The request must be addressed to the Bank at its then
principal place of business.

14.2    Timing of Response. Upon receipt of a claim, the Plan Administrator
shall advise the Claimant that a reply will be forthcoming within ninety (90)
days and shall, in fact, deliver such reply within such period. The Plan
Administrator may, however, extend the reply period for an additional ninety
(90) days for reasonable cause. If the claim is denied in whole or in part, the
Plan Administrator shall adopt a written opinion, using language calculated to
be understood by the Claimant, setting forth:

(1) The specific reason or reasons for such denial;

(2) The specific reference to pertinent provisions of this Agreement on which
such denial is based;

(3) A description of any additional material or information necessary for the
Claimant to perfect his or her claim and an explanation why such material or
such information is necessary;

(4) Appropriate information as to the steps to be taken if the Claimant wishes
to submit the claim for review; and

(5) The time limits for requesting a review under Section 14.3 and for review
under Section 14.4 hereof.

14.3    Request for Review. Within sixty (60) days after the receipt by the
Claimant of the written opinion described in Section 14.2, the Claimant may
request in writing that the determination of the Plan Administrator be reviewed.
Such request must be addressed to the Bank, at its then principal place of
business. The Claimant or his or her duly authorized representative may, but
need not, review the pertinent documents and submit issues and comments in
writing for consideration by the Plan Administrator. If the Claimant does not
request a review of the Plan Administrator’s determination within such sixty
(60) day period, he or she shall be barred and estopped from challenging the
Plan Administrator’s determination.

14.4    Review of Decision. The Plan Administrator will review its determination
within sixty (60) days after receipt of a request for review. After considering
all materials presented by the Claimant, the Plan Administrator will render a
written opinion, written in a manner calculated to be understood by the
Claimant, setting forth the specific reasons for the decision and containing
specific references to the pertinent provisions of this Agreement on which the
decision is based. If special circumstances require that the sixty (60) day time
period be extended, the Plan Administrator will so notify the Claimant and will
render the decision as soon as possible, but no later than one hundred twenty
(120) days after receipt of the request for review.

ARTICLE XV

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Exhibit 10.11

"Amendment"

15.1    This Agreement may not be amended, altered, or modified, except by a
written instrument signed by the parties hereto, or their respective successors
or assigns, and may not be otherwise terminated except as provided herein.
ARTICLE XVI
"Miscellaneous"

16.1     Binding Effect. This Agreement shall be binding upon and inure to the
benefit of the Bank and its successors and assigns, and upon the Insured, the
Insured’s successors, assigns, heirs, executors, administrators and
beneficiaries.

16.2    No Guarantee of Employment. This Agreement is not an employment policy
or contract. It does not give the Insured the right to remain an employee of the
Bank, nor does it interfere with the Bank’s right to discharge the Insured. It
also does not require the Insured to remain an Insured nor interfere with the
Insured’s right to terminate employment at any time.
    
16.3    Notices. Any notice, consent or demand required or permitted to be given
under the provisions of this Agreement shall be in writing, and shall be signed
by the party giving or making the same. If such notice, consent or demand is
mailed to a party hereto, it shall be sent by United States certified mail,
postage prepaid, addressed to such party’s last known address as shown on the
records of the Bank. The date of such mailing shall be deemed the date of
notice, consent or demand.

16.4    Applicable Law. This Agreement and the rights of the parties hereunder,
shall be governed by and construed according to the laws of the State of
Georgia, except to the extent preempted by the laws of the United States of
America.

16.5    Gender. Whenever in this Agreement words are used in the masculine or
neutral gender, they shall be read and construed as in the masculine, feminine
or neutral gender, whenever they should so apply.

16.6    No Third Party Beneficiaries. The benefits of this Agreement shall not
inure to any third party. This Agreement shall not be construed as creating any
rights, claims, or cause of action against the Bank or any of its officers,
directors, agents, or employees in favor of any person or entity other than the
Insured.
16.7    Severability. If any one or more of the provisions hereof is declared
invalid, illegal, or unenforceable in any jurisdiction, the validity, legality,
and enforceability of the remaining provisions shall not in any way be affected
or impaired, and that invalidity, illegality, or unenforceability in one
jurisdiction shall not affect the validity, legality, or enforceability of the
remaining provisions hereof.
16.8     Entire Agreement. This Agreement, along with the Insured’s beneficiary
designation form, constitutes the entire agreement between the Bank and the
Insured as to the subject matter hereof. No rights are granted to the Insured
under this Agreement other than those specifically set forth herein.

IN WITNESS WHEREOF, the parties hereto have executed this Agreement this _____
day of ________________, 2014.

 

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Exhibit 10.11

By:                  

By:                  

Print Name:               

Print Name:               

Insured
Bank Officer

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Exhibit 10.11

EXHIBIT A

The following life insurance Policies are subject to the attached Split-Dollar
Agreement:

Insurer:            

Insured:                     

Policy Number:                 

Face Amount:                        

Date of Issue:                    

Insurer:            

Insured:                     

Policy Number:                 

Face Amount:                        

Date of Issue:                    

Insurer:            

Insured:                     

Policy Number:                 

Face Amount:                        

Date of Issue:                    

Insurer:            

Insured:                     

Policy Number:                 

Face Amount:                        

Date of Issue:                    

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