EXHIBIT 10.1

CHANGE IN CONTROL AGREEMENT

     THIS CHANGE IN CONTROL AGREEMENT (this “Agreement”) is made by and between
Affirmative Insurance Holdings, Inc., a Delaware corporation (the “Company”),
and ___(the “Executive”), to be effective ___(the “Effective Date”).

RECITALS:

     A. The Company is a holding company for a group of insurance agencies and
property and casualty insurance subsidiaries which offer primary insurance
primarily on personal risks;

     B. The Board of Directors recognizes that the possibility of a Change in
Control (as defined below) affecting the Company, and the uncertainty which it
may raise among management personnel, may result in the departure or distraction
of management personnel to the detriment of the Company and its stockholders;

     C. The Board of Directors considers it essential to the best interests of
the Company and its stockholders that its key executives be incentivized to
remain with the Company, and to continue to devote their full attention and
dedication to the Company’s business and their assigned duties, in the event of
an actual or likely Change in Control;

     D. The Board of Directors believes the Executive is a key executive of the
Company and, in the event of an actual or likely Change in Control, the Board of
Directors wants the Executive to continue performing his or her duties, to
assess the impact of the potential Change in Control, to advise the Company
whether the potential Change in Control is in the best interests of the Company
and its shareholders, to assist in implementing the Change in Control, and to
take such other actions as the Board might determine to be appropriate under the
circumstances, all without the Executive being distracted by personal concerns
about the impact of the potential Change in Control on the Executive;

     E. The Company and the Executive each recognize and hereby acknowledge that
the Executive’s employment with the Company is and shall continue to be
terminable at will, without prior notice, by either the Company or the
Executive; and

     F. The Company and the Executive each hereby acknowledge that this
Agreement is not intended to be, and shall not be construed as, an express or
implied contract of employment between the Company and the Executive

     NOW, THEREFORE, in consideration of the mutual covenants contained herein,
the Company and the Executive hereby agree as follows:

     1. Circumstances Triggering Receipt of Severance Benefits

          (a) Subject to Section 1(c) below, and conditioned on the Executive’s
compliance with the Confidential Information, Non-Compete and Non-Solicitation
covenants

 

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contained in Section 6 hereof, and the Executive’s execution of a Waiver and
Release Agreement satisfactory to the Company, the Company will provide the
Executive with the benefits set forth in Sections 3 and 5 below upon any
termination of the Executive’s employment:

         (i) by the Company at any time within the first twenty-four (24) months
after a Change in Control;

         (ii) by the Company at any time within sixty (60) days prior to a
Change in Control; or

         (iii) by the Executive for “Good Reason” (as defined in Section 1(b)
below) at any time within the first twenty-four (24) months after a Change in
Control.

          (b) For purposes of Section 1(a)(iii) above, the Executive will be
entitled to terminate employment with the Company and its subsidiaries for “Good
Reason” after a Change in Control if:

         (i) without the Executive’s written consent, one or more of the
following events occurs at any time during the first twenty-four (24) months
after such Change in Control:

            (1) the Executive is not appointed to, or is otherwise removed from,
any office, title or position with the Company or its subsidiaries that is held
by the Executive ninety (90) days prior to the Change in Control for any reason
other than for Cause;

            (2) the Executive (i) suffers a significant adverse change in the
nature or scope of the authorities, powers, functions, responsibilities,
reporting relationships, or duties attached to the position with the Company
which the Executive as in effect at any time within ninety (90) days preceding
the date of a Change in Control or at any time thereafter, or (ii) is assigned
any duties or responsibilities which are inconsistent with his or her status,
office, title, position or responsibilities as in effect at any time within
ninety (90) days preceding the date of a Change in Control or at any time
thereafter;

            (3) the Executive has a change in condition or circumstances that
makes it materially more difficult for the Executive to carry out the duties and
responsibilities of his or her office that existed at any time within ninety
(90) days preceding the date of a Change in Control or at any time thereafter;

            (4) the Executive’s base salary is reduced below that in effect
immediately prior to the Change in Control or there is a failure to pay the
Executive any compensation or benefits to which he is entitled within five days
of the date due;

            (5) the Executive’s principal office is moved, without the
Executive’s consent, to a location that is more than thirty (30) miles from its

 

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location immediately prior to the Change in Control, except for reasonably
required travel on the Company’s business that is not materially greater than
such travel requirements prior to the Change in Control;

            (6) the Company fails to (A) continue in effect (without reduction
in benefit level and/or reward opportunities) any material compensation or
employee benefit plan in which the Executive was participating at any time
within ninety (90) days preceding the date of a Change in Control or at any time
thereafter, unless such plan is replaced with a plan that provides substantially
equivalent compensation or benefits to the Executive or (B) provide the
Executive with compensation and benefits, in the aggregate, at least equal (in
terms of benefit levels and/or reward opportunities) to those provided for under
each other employee benefit plan, program and practice in which the Executive
was participating at any time within 90 days preceding the date of a Change in
Control or at any time thereafter;

            (7) the Company becomes insolvent, or the filing by any person or
entity, including the Company or any of its subsidiaries, of a petition for
bankruptcy of the Company, or other relief under any other moratorium or similar
law, which petition is not dismissed within 60 days;

            (8) there is material breach by the Company of this Agreement;

            (9) there is a purported termination of the Executive’s employment
for Cause by the Company which does not comply with the terms of this Agreement;
or

            (10) the Company fails to comply with and satisfy its obligations
under Section 7(a) hereof.

The Executive’s right to terminate his employment for Good Reason shall not be
affected by his incapacity due to physical or mental illness; and.

         (ii) the Executive notifies the Company in writing (addressed in care
of the Chairman of the Board of the Company) of the occurrence of such event by
way of a Notice of Termination.

          (c) Notwithstanding Sections 1(a) and 1(b) above, no benefits will be
payable by reason of this Agreement in the event of:

         (i) termination of the Executive’s employment with the Company by
reason of the Executive’s death or Disability, so long as neither the Executive
nor the Company previously received a Notice of Termination for the Executive;

         (ii) termination by the Executive of the Executive’s employment with
the Company at or after age sixty-five (65) if the Executive is then eligible
for retirement; or

 

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         (iii) termination of the Executive’s employment with the Company for
Cause.

This Section 1(c) will not preclude the payment of any amounts otherwise payable
to the Executive under any of the Company’s employee benefits plans, programs
and arrangements and/or under any employment agreement.

     2. Notice of Termination. Any termination of the Executive’s employment
with the Company as contemplated by Section 1 above will be communicated by
written notice to the Executive or the Company delivered in person or by
certified mail. Any “Notice of Termination” will: (i) state the effective date
of termination (the “Termination Date”); and (ii) state the specific provision
in this Agreement being relied upon for termination.

     3. Termination Benefits. Subject to the conditions set forth in Section 1
above, the Company will pay or provide to the Executive (net of any applicable
payroll or other taxes required to be withheld) the following:

          (a) the Company shall pay the Executive in cash within thirty
(30) days of the Termination Date an amount equal to all Accrued Compensation
and the Pro Rata Bonus;

          (b) at the end of each of the twenty-four (24) consecutive calendar
months periods following the Termination Date, the Company shall pay to the
Executive in cash an amount equal to one-twelfth of the Base Amount (including
any increases in base salary); and

          (c) (A) for a period of twenty-four (24) months following the
Termination Date or (B) for such longer period as any plan, program, practice or
policy may provide, the Company shall continue benefits to the Executive and/or
the Executive’s family at least equal to those which would have been provided to
them in accordance with the Company’s plans, programs, practices and policies
providing medical, dental, health, death and disability benefits if the
Executive’s employment had not been terminated in accordance with the most
favorable plans, practices, programs or policies of the Company and its
affiliated companies as in effect and applicable generally to other peer
executives and their families during the 90-day period immediately preceding the
Executive’s termination of employment; provided, however, that if the Executive
becomes reemployed with another employer and is eligible to receive medical and
other welfare benefits under another employer-provided plan, the medical and
other welfare benefits described herein shall be secondary to those provided
under such other plan during such applicable period of eligibility.

     4. Limitation on Payments. In the event that the payments and other
benefits provided for in this Agreement or otherwise payable to the Executive
(i) constitute “parachute payments” within the meaning of Section 280G of the
Internal Revenue Code of 1986, as amended (the “Code”), and (ii) but for this
Section 4, would be subject to the excise tax imposed by Section 4999 of the
Code (or any corresponding provisions of state income tax law), then the
Executive’s benefits hereunder shall be either:

          (a) delivered in full, or

 

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          (b) delivered as to such lesser extent which would result in no
portion of such benefits being subject to excise tax under Section 4999 of the
Code,

whichever of the foregoing amounts, taking into account the applicable federal,
state and local income taxes and the excise tax imposed by Section 4999, results
in the receipt by the Executive on an after-tax basis, of the greater amount of
benefits, notwithstanding that all or some portion of such benefits may be
taxable under Section 4999 of the Code. Unless the Company and the Executive
otherwise agree in writing, any determination required under this Section 4
shall be made in writing by the Company’s independent public accountants (the
“Accountants”), whose determination shall be conclusive and binding upon the
Executive and the Company for all purposes. For purposes of making the
calculations required by this Section 4, the Accountants may make reasonable
assumptions and approximations concerning applicable taxes and may rely on
reasonable, good faith interpretations concerning the application of
Sections 280G and 4999 of the Code. The Company and the Executive shall furnish
to the Accountants such information and documents as the Accountants may
reasonably request in order to make a determination under this Section. The
Company shall bear all costs the Accountants may reasonably incur in connection
with any calculations contemplated by this Section 4. In the event that
subsection (a) above applies, then Executive shall be responsible for any excise
taxes imposed with respect to such benefits. In the event that subsection
(b) above applies, then each benefit provided hereunder shall be proportionately
reduced to the extent necessary to avoid imposition of such excise taxes.

     5. Termination. Except as otherwise provided in Section 1 above, the
Executive’s employment may be terminated as follows:

          (a) prior to a Change in Control, by either the Company or the
Executive for any reason, including, but not limited to, upon the resignation or
death of the Executive;

          (b) following a Change in Control:

         (1) by the Company due to the Disability or death of the Executive upon
delivery of a Notice of Termination to the Executive or his estate;

         (2) by the Company for Cause or without Cause, in either event upon
delivery of a Notice of Termination to the Executive; or

         (3) by the Executive for Good Reason or without Good Reason upon
delivery of a Notice of Termination to the Company.

Except as otherwise provided in Section 3 above, if the Executive’s employment
with the Company is terminated (i) by reason of the Executive’s resignation or
death, or (ii) by the Company for Disability or Cause, the Company shall pay to
the Executive (or in the case of his or her death, the Executive’s estate)
within thirty (30) days after the Termination Date a lump sum cash payment equal
to the Accrued Compensation.

 

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     7. Restrictive Covenants.

          (a) Confidential Information. Commencing on the date hereof and during
the Term, the Company agrees to provide Executive with Confidential Information
(as defined below). Commencing on the date hereof, and at all times thereafter,
Executive agrees that he will not divulge or disclose to anyone (other than the
Company or any persons employed or designated by the Company) any Confidential
Information. Confidential Information shall include all information of a
confidential nature relating to the business of the Company or any of its
subsidiaries or affiliates, including, without limitation, customer lists,
contract terms, marketing plans, business plans, financial data, cost
information, sales data, or business opportunities whether for existing, new or
developing businesses, and Executive further agrees not to disclose, publish or
make use of any such knowledge or Confidential Information at any time,
including in any future employment, without the consent of the Company.

          (b) Non-Compete. In consideration of the parties’ various mutual
promises contained herein, including without limitation those involving
Confidential Information, Executive agrees that commencing on the date hereof
and during the Term, and upon termination of Executive’s employment by Company
after a Change in Control per Section 1(a)(i), by Company prior to a Change in
Control per Section 1(a)(ii), or by Executive for “Good Reason” (as defined in
Section 1(b) herein), Executive agrees not to enter into or engage in any phase
of the business conducted by the Company in any state in which the Company is
conducting business on the date of termination of Executive’s employment with
the Company, either as an individual for his own account, as a partner or joint
venturer, or as an employee, agent, officer, director, or substantial
shareholder of a corporation or otherwise for a period of two (2) years
following the date of Executive’s termination of his employment with the
Company. As of the date of execution of this Agreement, the business conducted
by the Company is defined as owning and operating (i) insurance companies
providing automobile insurance coverage of any type or class, (ii) underwriting
agencies (or managing general agencies) that produce and administer automobile
insurance, and (iii) retail agencies that sell automobile insurance policies.
Notwithstanding the foregoing, in the event Executive’s employment is not
terminated for Cause, if Executive reasonably shows that his proposed employment
is not directly competitive with the Company’s business, Executive may enter
into such employment.

          (c) Non-Solicitation In consideration of the parties’ various mutual
promises contained herein, including without limitation those involving
Confidential Information, Executive agrees that commencing on the date hereof
and during the Term and upon termination of Executive’s employment, whether
voluntary or involuntary, Executive agrees not to directly or indirectly solicit
either (i) any employees of the Company to leave their employment with the
Company for employment with any other entity, or (ii) business in the area of
automobile insurance from any entity, organization or person which has
contracted with the Company, which has been doing business with the Company,
from which the Company was soliciting business at the time of Executive’s
termination, or from which Executive knew or had reason to know that the Company
was going to solicit business at the time of Executive’s termination, in each
case for a two (2) years period from the date of Executive’s termination of his
employment with the Company.

 

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          (d) Enforcement. Executive and the Company acknowledge and agree that
any of the covenants contained in this Section 6 may be specifically enforced
through injunctive relief, but such right to injunctive relief shall not
preclude Company from other remedies which may be available to it.

          (e) Reformation. The Company and Executive agree and stipulate that
the agreements and covenants not to compete contained in this Section 5 are fair
and reasonable in light of all of the facts and circumstances of the
relationship between Executive and the Company; however, Executive and the
Company are aware that in certain circumstances courts have refused to enforce
certain terms of agreements not to compete. Therefore, in furtherance of, and
not in derogation of the provisions of this Section 6, the Company and Executive
agree that in the event a court should decline to enforce any provision of this
Section 6, that this Section 6 shall be deemed to be modified or reformed to
restrict Executive’s competition with the Company or its affiliates to the
maximum extent, as to time, geography and business scope, that the court shall
find enforceable; provided, however, in no event shall the provisions of this
Section 6 be deemed to be more restrictive to Executive than those contained
herein.

          (f) Termination. Notwithstanding any provision to the contrary
otherwise contained in this Agreement, the agreements and covenants contained in
this Section 6 shall not terminate upon Executive’s termination of his
employment with the Company or upon the termination of this Agreement under any
other provision of this Agreement.

     7. Successors, Binding Agreement.

          (a) This Agreement shall be binding upon and shall inure to the
benefit of the Company (including each of its subsidiaries), its successors and
assigns and any person, firm, corporation or other entity which succeeds to all
or substantially all of the business, assets or property of the Company. The
Company will require any successor (whether direct or indirect, by purchase,
merger, consolidation, or otherwise) to all or substantially all of the
business, assets or property of the Company, to expressly assume and agree to
perform this Agreement in the same manner and to the same extent that the
Company would be required to perform it if no such succession had taken place.
As used in this Agreement, the “Company” shall mean the Company as hereinbefore
defined and any successor to its business, assets or property as aforesaid which
executes and delivers an agreement provided for in this Section 6 or which
otherwise becomes bound by all the terms and provisions of this Agreement by
operation of law.

          (b) This Agreement and all rights of the Executive hereunder shall
inure to the benefit of and be enforceable by the Executive’s personal or legal
representatives, executors, administrators, successors, heirs, distributees,
devisees and legatees. If the Executive should die while any amounts are due and
payable to him hereunder, all such amounts, unless otherwise provided herein,
shall be paid to the Executive’s designated beneficiary or, if there be no such
designated beneficiary, to the legal representatives of the Executive’s estate.

     8. Fees and Expenses. In the event that the Executive’s employment is
terminated during the twenty-four (24) month period after a Change in Control
either by the Company either

 

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for Cause or without Cause or by the Executive for Good Reason, the Company
shall reimburse the Executive for any reasonable attorneys’ fees, expenses and
court costs incurred by the Executive as a result of any litigation by the
Executive regarding the validity, enforceability or interpretation of any
provision of this Agreement (excluding Section 5) (including as a result of any
litigation by the Executive regarding the benefits payable to the Executive
pursuant to this Agreement) upon receipt of proof of such expenses regardless of
which party, if any, prevails in the contest.

     9. Notice. All notices and other communications provided for in this
Agreement (including the Notice of Termination) shall be in writing and shall be
deemed to have been duly given upon personal delivery or receipt when sent by
certified mail, return receipt requested, postage prepaid, or by a nationally
recognized overnight courier service that provides written proof of delivery,
and shall be addressed as follows (or to such other address as either party
shall have furnished to the other in writing in accordance herewith):

             
 
  If to the Executive:        
 
           
 
           
 
           
 
           
 
           
 
           
 
           
 
           
 
  If to the Company:   Affirmative Insurance Holdings, Inc.    
 
      4450 Sojourn Drive, Suite 500    
 
      Addison, Texas, 75001    
 
      Attention: Chief Executive Officer    
 
      Copy to: General Counsel    

     10. Settlement of Claims. The Company’s obligation to make the payments
provided for in this Agreement and to otherwise perform its obligations
hereunder shall not be affected by any circumstances, including, without
limitation, any set-off, counterclaim, recoupment, defense or other right which
the Company may have against the Executive or others. The Company may, however,
withhold from any benefits payable under this Agreement all federal, state, city
or other taxes as shall be required pursuant to any law or governmental
regulation or ruling.

     11. Modification and Waiver. No provisions of this Agreement may be
modified, waived or discharged unless such waiver, modification or discharge is
agreed to in writing and signed by the Executive and the Company. No waiver by
any party hereto at any time of any breach by the other party hereto of, or
compliance with, any condition or provision of this Agreement to be performed by
such other party shall be deemed a waiver of similar or dissimilar provisions or
conditions at the same or at any prior or subsequent time.

     Notwithstanding any other provisions of this Agreement to the contrary, the
parties hereto agree that they will in good faith amend this Agreement in any
manner reasonably necessary in order to comply with Code Section 409A, as
enacted by the American Jobs Creation Act of 2004, and the parties further
understand and agree that any provision in this Agreement that shall violate the
requirements of Code Section 409A shall be of no force and effect after such
amendment.

 

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     12. Governing Law. This Agreement shall be governed by and construed and
enforced in accordance with the laws of the State of Texas without giving effect
to the conflict of laws principles thereof.

     13. Severability. The provisions of this Agreement shall be deemed
severable, and the invalidity or unenforceability of any provision shall not
affect the validity or enforceability of the other provisions hereof.

     14. Entire Agreement. This Agreement constitutes the entire agreement
between the parties hereto and supersedes all prior agreement, if any,
understandings and arrangements, oral or written, between the parties hereto
with respect to the subject matter hereof.

     15. Headings. The headings of Sections herein are included solely for
convenience of reference and shall not control the meaning or interpretation of
any of the provisions of this Agreement.

     16. Counterparts. This Agreement may be executed in one or more
counterparts, each shall be deemed an original but all of which together shall
constitute one and the same instrument.

     17. Definitions. For purposes of this Agreement, the following terms shall
have the following meanings:

          (a) “Accrued Compensation” shall mean an amount which shall include
all amounts earned or accrued through the Termination Date but not paid as of
the Termination Date, including without limitation, (i) base salary,
(ii) deferred compensation accumulated under any plan, arrangement or agreement,
(iii) reimbursement for reasonable and necessary expenses incurred by the
Executive on behalf of the Company prior to Termination Date, and (iv) bonuses
and incentive cash compensation (other than the Pro Rata Bonus).

          (b) “Base Amount” shall mean the greater of the Executive’s annual
base salary at the highest rate in effect at any time during the 90-day period
prior to a Change in Control, and shall include all amounts of his base salary
that are deferred under any plans, arrangements or agreements of the Company or
any of its affiliates.

          (c) “Board” shall mean the Board of Directors of the Company.

          (d) “Bonus Amount” shall mean the greater of (i) the most recent
annual cash bonus paid or payable to the Executive, or, if greater, the annual
cash bonus paid or payable for the year ended prior to the fiscal year during
which a Change in Control occurred, or (ii) the average of the annual cash
bonuses paid or payable during the three full fiscal years ended prior to a
Change in Control (or such lesser period for which annual bonuses were paid or
payable to the Executive).

          (e) “Cause” shall mean

 

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          (i) neglect of his or her material duties or failure to perform his or
her material obligations under this Agreement that materially causes harm to the
Company or that, in the reasonable judgment of the Company, has materially
damaged or interfered with the Company’s relationships with its customers,
suppliers, employees or other agents; provided, however, that the Company shall
give the Executive written notice of any actions or omissions alleged to
constitute Cause under this subparagraph (a) and the Executive shall have
forty-five (45) days to cure any such alleged Cause;

          (ii) refusal or failure to follow lawful directives of the Board that
are not arbitrary and capricious; provided, however, that the Company shall give
the Executive written notice of any actions or omissions alleged to constitute
Cause under this subparagraph (b) and the Executive shall have forty-five
(45) days to cure any such alleged Cause;

          (iii) conviction of, or a plea of nolo contendere to, or deferred
adjudication for (x) a felony relating to the Company’s assets, activities,
operations or employees or (y) a felony or a misdemeanor involving moral
turpitude that causes harm to the Company or that, in the good faith judgment of
the Company, has damaged or interfered with the Company’s relationships with its
customers, suppliers, employees or other agents;

          (iv) substance abuse or illegal use of drugs that materially impairs
Executive’s performance, that materially causes harm to the Company or that, in
the reasonable judgment of the Company, has materially damaged or interfered
with the Company’s relationships with its customers, suppliers, employees or
other agents;

          (v) commission of an act of fraud, illegality, theft or intentional
dishonesty in the course of Executive’s employment with the Company and relating
to $5,000 or more of the Company’s assets, or causing $5,000 or more in harm or
damages with respect to the Company’s activities, operations or employees; or

          (vi) breach by Executive of Section 6 of this Agreement.

          (f) A “Change in Control” shall mean the happening during the Term of
any of the following:

          (i) when any “person” as such term is used in Section 13(d) and 14(d)
of the Exchange Act (other than the Company or any Company employee benefit
plan, including its trustees) is or becomes the “beneficial owner” (as defined
in Rule 13d-3 under the Exchange Act), directly or indirectly of securities of
the Company representing twenty percent (20%) or more of the combined voting
power of the Company’s then outstanding securities;

          (ii) the occurrence of any transaction or event relating to the
Company required to be described pursuant to the requirements of Item 6(e) of
Schedule 14A of Regulation 14A under the Exchange Act;

 

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          (iii) when, during any period of two (2) consecutive years during the
Term, the individuals who, at the beginning of such period, constitute the Board
cease, for any reason other than death, to constitute at least a majority
thereof, unless each director who was not a director at the beginning of such
period was elected by, or on the recommendation of, at least two-thirds (2/3) of
the directors at the beginning of such period; or

          (iv) the occurrence of a transaction requiring stockholder approval
for the acquisition of the Company by an entity other than the Company through
purchase of assets, or by merger, or otherwise.

          (g) “Compensation Committee” shall mean the Compensation Committee of
the Board.

          (h) “Disability” shall mean the inability of the Executive to perform
his or her duties to the Company on account of physical or mental illness for a
period of six consecutive full months, or for a period of eight full months
during any 12-month period. The Executive’s employment shall terminate in such a
case on the last day of the applicable period; provided, however, in no event
shall the Executive be terminated by reason of Disability unless (i) the
Executive is eligible for the long-term disability benefits under the Company’s
long-term disability insurance policy or plan and (ii) the Executive receives
written notice from the Company, at least 30 days in advance of such
termination, stating its intention to terminate the Executive for reason of
Disability and setting forth in reasonable detail the facts and circumstances
claimed to provide a basis for such termination.

          (i) “Effective Date” shall mean the day and year first above written.

          (j) “Exchange Act” shall mean the Securities Exchange Act of 1934, as
amended.

          (k) “Notice of Termination” shall have the meaning defined in
Section 2 above.

          (l) “Pro Rata Bonus” shall mean an amount equal to the Bonus Amount
multiplied by a fraction the numerator of which is the number of days in the
applicable year through the Termination Date and the denominator of which is
365.

          (m) “Term” shall mean, unless earlier terminated as provided herein,
this Agreement shall be for a term of two (2) years from the Effective Date.
Thereafter, the Term shall be automatically extended for an additional year on
each anniversary of the Effective Date, unless written notice of non-extension
is provided by either party to the other party at least 90 days prior to such
anniversary.

          (n) “Termination Date” shall have the meaning defined in Section 2
above.

 

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[SIGNATURES ON FOLLOWING PAGE]

 

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     IN WITNESS WHEREOF, the Company has caused this Agreement to be executed by
its officer thereunto duly authorized, and the Executive has signed this
Agreement, effective as of the date first above written.

     
 
  AFFIRMATIVE INSURANCE HOLDINGS, INC.
 
   
 
   
 
   
 
  By:
 
  Its:
 
   
 
  EXECUTIVE:
 
   
 
   
 
   
 
  By:

 

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