Exhibit 10.3

Option No.________

INTERCEPT PHARMACEUTICALS, INC.

2012 EQUITY INCENTIVE PLAN

STOCK OPTION GRANT

Stock Option Grant Notice (Employees and Consultants)

Intercept Pharmaceuticals, Inc. (the “Company”) hereby grants to the participant
named below (the “Participant”) an option of the type specified below (this
“Option”) to purchase up to the number of shares of the Company’s common stock,
par value $0.001 per share (the “Shares”), set forth below at the exercise price
set forth below. This Option is subject to all of the terms and conditions set
forth in this Stock Option Grant Notice (this “Grant Notice”), the Intercept
Pharmaceuticals, Inc. 2012 Equity Incentive Plan (the “Plan”) and the Stock
Option Agreement attached hereto (the “Agreement”). Capitalized terms not
defined in this Grant Notice but defined in the Agreement or the Plan will have
the meanings assigned to such terms in the Agreement or the Plan, as applicable.
Except as expressly provided in the Agreement, in the event of any conflict
between the provisions of this Grant Notice or the Agreement and those of the
Plan, the provisions of the Plan will control.

 

 

 

 

1.

Name and Address of Participant:

 

 

 

 

 

 

 

 

 

 

2.

Date of Grant:

 

 

 

 

3.

Type of Option:

 

 

 

 

4.

Number of Shares Underlying Option:

 

 

 

 

5.

Exercise Price Per Share:

 

 

 

 

6.

Option Expiration Date:

 

 

 

 

7.

Vesting Commencement Date:

 

 

8.            Vesting Schedule:  This Option shall become exercisable (and the
Shares issued upon exercise shall be vested) as follows provided the Participant
is an Employee, director or Consultant of the Company or an Affiliate on the
applicable vesting date (see vesting schedule below):

[INSERT VESTING SCHEDULE]

See Section 1(b) of the Agreement for vesting in the event of a Change of
Control (as defined in the Agreement). The foregoing vesting provisions are
cumulative and are subject to the other terms and conditions of the Agreement
and the Plan.

By accepting this Option, whether electronically or otherwise, the Participant
acknowledges receipt of, and understands and agrees to, this Grant Notice, the
Agreement and the Plan. Unless otherwise specified in a written agreement
between the Company and the Participant, this Grant Notice, the Agreement and
the Plan set forth the entire understanding between the Participant and the
Company regarding this Option and supersede all prior oral and written
agreements on the terms of this Option.

INTERCEPT PHARMACEUTICALS, INC.

2012 EQUITY INCENTIVE PLAN

STOCK OPTION AGREEMENT

Pursuant to the Stock Option Grant Notice to which this agreement is attached
(the “Grant Notice”) and this Stock Option Agreement (this “Agreement”),
Intercept Pharmaceuticals, Inc. (the “Company”) has granted to the participant
named in the Grant Notice (the “Participant”) an option of the type specified in
the Grant Notice (this “Option”), under and for the purposes set forth in the
Intercept Pharmaceuticals, Inc. 2012 Equity Incentive Plan (the “Plan”), to
purchase up to the number of shares of the Company’s common stock, par value
$0.001 per share (the “Shares”), indicated in the Grant Notice at the exercise
price indicated in the Grant Notice (as may be adjusted from time to time in
accordance with this Agreement and the Plan, the “Exercise Price”). Capitalized
terms not defined in this Agreement or in the Grant Notice but defined in the
Plan will have the meanings assigned to such terms in the Plan.

The terms and conditions of this Option, in addition to those set forth in the
Grant Notice and the Plan, are as follows:

1.            EXERCISABILITY OF OPTION.

(a)          Subject to the terms and conditions set forth in this Agreement and
the Plan, this Option shall become vested and exercisable as set forth in the
Grant Notice. This Option shall continue to vest and become exercisable in
accordance with its terms for so long as the Participant is an Employee,
director or Consultant of the Company or an Affiliate.

(b)          Notwithstanding the foregoing, except to the extent specifically
provided to the contrary in any employment agreement between the Participant and
the Company or an Affiliate, in the event of (i) a Change of Control (as defined
below) and the Participant’s service with the Company, the acquiring or
succeeding corporation or any Affiliate of any of the foregoing is terminated by
such entity for any reason other than for Cause within 12 months of the Change
of Control, then, immediately prior to such termination, this Option, to the
extent then-outstanding, shall become fully vested and exercisable, or (ii) a
Corporate Transaction (as defined in Section 24(b) of the Plan) that is a Change
of Control in which the acquiring entity does not assume this Option, then,
immediately prior to the Change of Control, this Option, to the extent
then-outstanding, shall become fully vested and exercisable.

For purposes of this Agreement, “Change of Control” means the occurrence of any
of the following events:

(i)           Ownership.  Any “Person” (as such term is used in Sections 13(d)
and 14(d) of the Securities Exchange Act of 1934, as amended) becomes the
“Beneficial Owner” (as defined in Rule 13d-3 under said Act), directly or
indirectly, of securities of the Company representing 50% or more of the total
voting power represented by the Company’s then-outstanding voting securities
(excluding for this purpose any such voting securities held by the Company or
its Affiliates or any employee benefit plan of the Company); or

(ii)          Merger/Sale of Assets.  (A) A merger or consolidation of the
Company whether or not approved by the Board of Directors, other than a merger
or consolidation which would result in the voting securities of the Company
outstanding immediately prior thereto continuing to represent (either by
remaining outstanding or by being converted into voting securities of the
surviving entity or the parent of such corporation) more than 50% of the total
voting power represented by the voting securities of the Company or such
surviving entity or parent of such corporation, as the case may be, outstanding
immediately after such merger or consolidation; or (B) the sale or disposition
by the Company of all or substantially all of the Company’s assets in a
transaction requiring stockholder approval; or

(iii)         Change in Board Composition.  A change in the composition of the
Board of Directors, as a result of which fewer than a majority of the directors
are Incumbent Directors. “Incumbent Directors” shall mean directors who either
(A) are directors of the Company as of the date of grant, or (B) are elected, or
nominated for election, to the Board of Directors with the affirmative votes of
at least a majority of the Incumbent Directors at the time of such election or
nomination (but shall not include an individual whose election or nomination is
in connection with an actual or threatened proxy contest relating to the
election of directors to the Company).

2.            TERM OF OPTION.

This Option shall terminate on the Option Expiration Date specified in the Grant
Notice (provided, that if this Option is designated in the Grant Notice as an
ISO and the Participant owns as of the date of grant of this Option more than
10% of the total combined voting power of all classes of capital stock of the
Company or an Affiliate, such date may not be more than five years from the date
of grant of this Option), but shall be subject to earlier termination as
provided herein or in the Plan.

If the Participant ceases to be an Employee, director or Consultant of the
Company or an Affiliate for any reason other than the termination of the
Participant for Cause (the date of such cessation of service, the “Termination
Date”), this Option, to the extent then vested and exercisable, and not
previously terminated in accordance with this Agreement, may be exercised by the
Participant or, as applicable, the Participant’s Survivors on or prior to the
earliest of the following:

(i)           in the event that the Participant ceases to be an Employee,
director or Consultant of the Company or an Affiliate other than for Cause or
due to the Disability or death of the Participant, the date that is three (3)
months after the Termination Date; provided, that the commencement of such
three-month period shall be tolled (subject to clause (iii) below) for so long
as the sale of any Shares received upon exercise of this Option on or after the
Termination Date (including in connection with a broker-assisted cashless
exercise) would result in (a) short swing profit liability for the Participant
under Section 16(b) of the Exchange Act or (b) a violation of the Company’s
insider trading policy; provided,  further, that, in the event of the
Participant’s Disability or death within such period, the Participant or, as
applicable, the Participant’s Survivors may exercise this Option on or prior to
the date that is one (1) year after the Termination Date;

(ii)          in the event that the Participant ceases to be an Employee,
director or Consultant of the Company or an Affiliate due to the Disability or
death of the Participant, the date that is one (1) year after the Termination
Date; or

(iii)         the Option Expiration Date specified in the Grant Notice.

The unvested portion of this Option shall not be exercisable and shall expire
and be cancelled on the Termination Date; provided, that, in the event that the
Participant ceases to be an Employee, director or Consultant of the Company or
an Affiliate due to the Disability or death of the Participant, and rights to
exercise this Option accrue periodically, a pro rata portion of any additional
vesting rights that would have accrued on the next vesting date had the
Participant not become Disabled or died shall vest and become exercisable as of
the Termination Date. Such proration shall be based upon the number of days
accrued in the current vesting period prior to the date of the Participant’s
termination of service due to Disability or death.

If the Participant ceases to be an Employee of the Company or an Affiliate but
continues after termination of employment to provide services to the Company or
an Affiliate as a director or Consultant, this Option shall continue to vest and
become exercisable until the Participant is no longer providing services to the
Company or an Affiliate as set forth above; provided, that if this Option is
designated in the Grant Notice as an ISO, it shall automatically convert and be
deemed a Non-Qualified Option as of the date that is three months from
termination of the Participant’s employment.

In the event the Participant’s service is terminated by the Company or an
Affiliate for Cause, the Participant’s right to exercise any unexercised portion
of this Option (even if vested) shall cease immediately as of the time the
Participant is notified his or her service is terminated for Cause, and this
Option shall thereupon terminate. Notwithstanding anything herein to the
contrary, if subsequent to the Participant’s termination, but prior to the
exercise of this Option, the Administrator determines that, either prior or
subsequent to the Participant’s termination, the Participant engaged in conduct
which would constitute Cause, then the Participant shall immediately cease to
have any right to exercise this Option and this Option shall thereupon
terminate.

3.            METHOD OF EXERCISING OPTION.

Subject to the terms and conditions of this Agreement, this Option may be
exercised by written notice to the Company or its designee (in a form designated
by the Company, which may include electronic notice) stating the number of
Shares with respect to which this Option is being exercised. Payment of the
Exercise Price for such Shares shall be made in accordance with Paragraph 9 of
the Plan. The Company shall deliver such Shares as soon as practicable after the
notice shall be received, provided,  however, that the Company may delay
issuance of such Shares until completion of any action or obtaining of any
consent, which the Company deems necessary under any applicable law (including,
without limitation, state securities or “blue sky” laws). The Shares as to which
this Option shall have been so exercised shall be registered in the Company’s
share register in the name of the person so exercising this Option (or, if this
Option shall be exercised by the Participant and if the Participant shall so
request in the notice exercising this Option, shall be registered in the
Company’s share register in the name of the Participant and another person
jointly, with right of survivorship) and shall be delivered as provided above to
or upon the written order of the person exercising this Option. In the event
this Option shall be exercised, pursuant to Section 2 hereof, by any person
other than the Participant, such notice shall be accompanied by appropriate
proof of the right of such person to exercise this Option. All Shares that shall
be purchased upon the exercise of this Option as provided herein shall be fully
paid and nonassessable.

4.            PARTIAL EXERCISE.

Exercise of this Option to the extent above stated may be made in part at any
time and from time to time within the above limits, except that no fractional
share shall be issued pursuant to this Option.

5.            PROHIBITIONS ON TRANSFER.

This Option shall not be transferable by the Participant otherwise than by will
or by the laws of descent and distribution. If this Option is a Non-Qualified
Option then it may also be transferred pursuant to a qualified domestic
relations order as defined by the Code or Title I of the Employee Retirement
Income Security Act or the rules thereunder. Except as provided above in this
Section 5, this Option shall be exercisable during the Participant’s lifetime
only by the Participant (or, in the event of legal incapacity or incompetency,
by the Participant’s guardian or representative) and shall not be assigned,
pledged or hypothecated in any way (whether by operation of law or otherwise)
and shall not be subject to execution, attachment or similar process. Any
attempted transfer, assignment, pledge, hypothecation or other disposition of
this Option or of any rights granted hereunder contrary to the provisions of
this Section 5, or the levy of any attachment or similar process upon this
Option shall be null and void.

6.            NO RIGHTS AS STOCKHOLDER.

The Participant shall have no rights as a stockholder with respect to Shares
subject to this Option until registration of the Shares in the Company’s share
register in the name of the Participant. Except as is expressly provided in the
Plan with respect to certain changes in the capitalization of the Company, no
adjustment shall be made for dividends or similar rights for which the record
date is prior to the date of such registration.

7.            ADJUSTMENTS.

This Option, including the number of Shares subject to this Option and the
Exercise Price, shall be subject to adjustment from time to time as provided for
in the Plan upon the occurrence of certain events described therein.

8.            TAXES.

The Participant acknowledges that any income or other taxes due from him or her
with respect to this Option or the Shares issuable pursuant to this Option shall
be the Participant’s responsibility. The Participant acknowledges and agrees
that (i) the Participant was free to use professional advisors of his or her
choice in connection with his or her acceptance of this Option, has received
advice from his or her professional advisors in connection with his or her
acceptance of this Option, understands its meaning and import, and has accepted
this Option freely and without coercion or duress; (ii) the Participant has not
received and is not relying upon any advice, representations or assurances made
by or on behalf of the Company or any Affiliate or any employee of or counsel to
the Company or any Affiliate regarding any tax or other effects or implications
of this Option, the Shares subject to this Option or other matters contemplated
hereby; and (iii) neither the Administrator, the Company, its Affiliates, nor
any of its or their officers or directors, shall be held liable for any
applicable costs, taxes, or penalties associated with this Option if, in fact,
the Internal Revenue Service were to determine that this Option constitutes
deferred compensation under Section 409A of the Code.

The Participant agrees that the Company may withhold from the Participant’s
remuneration, if any, the amount of federal, state and local withholding taxes
attributable to such amount that is considered compensation includable in such
person’s gross income in connection with the exercise of this Option and, as a
condition to the exercise of this Option, the Participant shall make
arrangements satisfactory to the Company to enable it to satisfy all such
withholding requirements. Without limiting the generality of the foregoing, at
the Company’s discretion, the amount required to be withheld may be withheld in
cash from such remuneration, or in kind from the Shares otherwise deliverable to
the Participant on exercise of this Option. The Participant further agrees that,
to the extent the Company does not withhold an amount from the Participant’s
remuneration sufficient to satisfy the Company’s income tax withholding
obligation, the Participant will reimburse the Company on demand, in cash, for
the amount under-withheld.

9.            SECURITIES LAWS COMPLIANCE.

The Participant specifically acknowledges and agrees that this Option and any
delivery of Shares hereunder shall be subject to compliance with the
requirements of the Securities Act and other applicable securities laws, rules
or regulations. In addition, applicable securities laws, rules or regulations
may restrict the ability of the Participant to resell Shares delivered
hereunder, including due to the Participant’s affiliation with the Company. The
Company shall not be obligated to issue the Shares if such issuance would
violate any applicable securities law, rule or regulation.

10.          NO OBLIGATION TO MAINTAIN RELATIONSHIP.

The Participant acknowledges that: (i) the Company is not by the Plan or this
Option obligated to continue the Participant as an Employee, director or
Consultant of the Company or an Affiliate; (ii) the Plan is discretionary in
nature and may be suspended or terminated by the Company at any time; (iii) the
grant of this Option is a one-time benefit which does not create any contractual
or other right to receive future grants of options, or benefits in lieu of
options; (iv) all determinations with respect to future grants, if any, will be
at the sole discretion of the Company; (v) the Participant’s participation in
the Plan is voluntary; (vi) the value of this Option is an extraordinary item of
compensation which is outside the scope of the Participant’s employment or
consulting contract, if any; and (vii) this Option is not part of normal or
expected compensation for purposes of calculating any severance, resignation,
redundancy, end of service payments, bonuses, long-service awards, pension or
retirement benefits or similar payments.

11.          IF OPTION IS INTENDED TO BE AN ISO.

If this Option is designated in the Grant Notice as an ISO, the Participant (or
the Participant’s Survivors) may qualify for the favorable tax treatment
provided to holders of options that meet the standards of Section 422 of the
Code and any provision of this Option or the Plan which conflicts with the Code
such that this Option would not be deemed an ISO shall be null and void, and any
ambiguities shall be resolved so that this Option qualifies as an ISO. The
Participant should consult with the Participant’s own tax advisors regarding the
tax effects of this Option and the

requirements necessary to obtain favorable tax treatment under Section 422 of
the Code, including, but not limited to, holding period requirements.

Notwithstanding the foregoing, to the extent that this Option is designated in
the Grant Notice as an ISO, but would be deemed not to be an ISO pursuant to
Section 422(d) of the Code because the Fair Market Value (determined as of the
date of grant of this Option) of Shares with respect to which this Option
becomes exercisable for the first time during any calendar year, when aggregated
with the Fair Market Values (determined as of the respective dates of grant of
such ISOs) of Shares with respect to which all other ISOs granted to the
Participant become exercisable for the first time during such calendar year,
exceeds $100,000, the portion of this Option representing such excess value
shall be treated as a Non-Qualified Option (applied pro-rata over all vesting
tranches of this Option in the applicable calendar year) and upon exercise the
Participant shall have taxable income measured by the difference between the
then Fair Market Value of the Shares received upon exercise and the price paid
for such Shares pursuant to this Option.

Neither the Company nor any Affiliate shall have any liability to the
Participant, or any other party, if this Option (or any part thereof) is
intended to be an ISO but is deemed not to be an ISO or for any action taken by
the Administrator, including without limitation the conversion of an ISO to a
Non-Qualified Option.

12.          NOTICE TO COMPANY OF DISQUALIFYING DISPOSITION OF AN ISO.

If this Option is designated in the Grant Notice as an ISO, the Participant
agrees to notify the Company in writing immediately after the Participant makes
a Disqualifying Disposition of any of the Shares acquired pursuant to the
exercise of this Option. A “Disqualifying Disposition” is defined in Section
424(c) of the Code and includes any disposition (including any sale) of such
Shares before the later of (a) two years after the date the Participant was
granted the ISO or (b) one year after the date the Participant acquired Shares
by exercising the ISO, except as otherwise provided in Section 424(c) of the
Code. If the Participant has died before the Shares are sold, these holding
period requirements do not apply and no Disqualifying Disposition can occur
thereafter.

13.          NOTICES.

Any notices required or permitted by the terms of this Agreement or the Plan
shall be given by recognized courier service, registered or certified mail,
return receipt requested, addressed as follows:

If to the Company:

Intercept Pharmaceuticals, Inc.
10 Hudson Yards, 37th Floor
New York, NY 10001

Attention: General Counsel

If to the Participant at the address set forth on the Grant Notice or to such
other address or addresses of which notice in the same manner has previously
been given. Any such notice shall be deemed to have been given upon the earlier
of receipt, one business day following delivery to a recognized courier service
or three business days following mailing by registered or certified mail.

The Company may, in its sole discretion, decide to deliver any documents related
to participation in the Plan and this Option by electronic means. By accepting
this Option, whether electronically or otherwise, the Participant consents to
receive such documents by electronic delivery and to participate in the Plan
through an online or electronic system established and maintained by the Company
or another third party designated by the Company.

14.          GOVERNING LAW.

The Grant Notice and this Agreement shall be governed by and construed in
accordance with the laws of the State of Delaware, without giving effect to the
conflict of law principles thereof. For the purpose of litigating any dispute
that arises under the Grant Notice, this Agreement or the Plan, each of the
Company and, by accepting this

Option, whether electronically or otherwise, the Participant hereby consents to
exclusive jurisdiction in New York and agrees that such litigation shall be
conducted in the state courts of New York County, New York or the federal courts
of the United States for the District of the Southern District of New York.

15.          BENEFIT OF AGREEMENT.

Subject to the provisions of the Plan and the other provisions hereof, the Grant
Notice and this Agreement shall be for the benefit of and shall be binding upon
the heirs, executors, administrators, successors and assigns of the parties
hereto.

16.          ENTIRE AGREEMENT.

The Grant Notice and this Agreement, together with the Plan, embodies the entire
agreement and understanding between the parties hereto with respect to the
subject matter hereof and supersedes all prior oral or written agreements and
understandings relating to the subject matter hereof. No statement,
representation, warranty, covenant or agreement not expressly set forth in the
Grant Notice or this Agreement shall affect or be used to interpret, change or
restrict the express terms and provisions of the Grant Notice or this Agreement;
provided,  however, in any event, the Grant Notice and this Agreement shall be
subject to and governed by the Plan. This Option is subject to all applicable
laws, rules, and regulations, and to such approvals by any governmental agencies
or national securities exchanges as may be required. In addition, this Option
(and any compensation paid or shares issued pursuant to this Option) is subject
to recoupment in accordance with The Dodd-Frank Wall Street Reform and Consumer
Protection Act and any implementing regulations thereunder, any clawback policy
adopted by the Company and any compensation recovery policy otherwise required
by applicable law.

17.          MODIFICATIONS AND AMENDMENTS.

The terms and provisions of the Grant Notice and this Agreement may be modified
or amended as provided in the Plan.

18.          WAIVERS AND CONSENTS.

Except as provided in the Plan, the terms and provisions of the Grant Notice and
this Agreement may be waived, or consent for the departure therefrom granted,
only by written document executed by the party entitled to the benefits of such
terms or provisions. No such waiver or consent shall be deemed to be or shall
constitute a waiver or consent with respect to any other terms or provisions of
the Grant Notice or this Agreement, whether or not similar. Each such waiver or
consent shall be effective only in the specific instance and for the purpose for
which it was given, and shall not constitute a continuing waiver or consent.

19.          DATA PRIVACY.

By accepting this Option, whether electronically or otherwise, the Participant:
(i) authorizes the Company and each Affiliate, and any agent of the Company or
any Affiliate administering the Plan or providing Plan recordkeeping services,
to disclose to the Company or any of its Affiliates such information and data as
the Company or any such Affiliate shall request in order to facilitate the grant
of options and the administration of the Plan; (ii) waives any data privacy
rights he or she may have with respect to such information or the sharing of
such information; and (iii) authorizes the Company and each Affiliate to store
and transmit such information in electronic form for the purposes set forth in
the Grant Notice and this Agreement.

20.          SEVERABILITY.

If all or any part of the Grant Notice, this Award Agreement or the Plan is
declared by any court or governmental authority to be unlawful or invalid, such
unlawfulness or invalidity will not invalidate any portion of the Grant Notice,
this Award Agreement or the Plan not declared to be unlawful or invalid. Any
section of the Grant Notice, this Award Agreement or the Plan (or part of such a
section) so declared to be unlawful or invalid shall, if possible, be construed
in a manner which will give effect to the terms of such section or part of a
section to the fullest extent possible while remaining lawful and valid.

21.          NON-U.S. PARTICIPANTS.

If the Participant works and/or resides outside of the United States, the
applicable terms and conditions set forth in Appendix A shall apply to this
Option. In addition, the Company reserves the right to impose other requirements
on the Participant to the extent the Company determines that such requirements
are necessary or advisable in order to comply with local law or facilitate the
administration of the Plan and to require the Participant to sign any additional
agreements or undertakings that may be necessary to accomplish the foregoing.

APPENDIX A

INTERCEPT PHARMACEUTICALS, INC.

2012 EQUITY INCENTIVE PLAN

STOCK OPTION AGREEMENT

TERMS AND CONDITIONS FOR NON-U.S. PARTICIPANTS

This Appendix includes additional or different terms and conditions that govern
this Option if the Participant works and/or resides outside of the United
States. This Appendix forms part of the Stock Option Agreement to which it is
attached (the “Agreement”). Capitalized terms not defined in this Appendix but
defined in the Agreement or the Plan will have the meanings assigned to such
terms in the Agreement or the Plan, as applicable. References within this
Appendix to “you” refer to the Participant.

These terms are general in nature, may not apply to your particular situation
and are based on securities, tax and other laws that are often complex and
subject to frequent change. As such, the Company strongly recommends that you do
not rely on this summary as your only source of information relating to the
consequences of your Option and participation in the Plan and further that you
consult your personal tax or legal advisors for advice as to how the laws in
your country apply to your situation. Note that if you are a citizen or resident
of a country other than the one in which you are working, additional
requirements, other than those described herein, may be applicable to you.

ALL NON-U.S. PARTICIPANTS

1.            TAXES (REPLACING SECTION 8 OF THE AGREEMENT)

The Participant acknowledges that any income or other taxes due from him or her
with respect to this Option or the Shares issuable pursuant to this Option shall
be the Participant’s responsibility. The Participant acknowledges and agrees
that (i) the Participant was free to use professional advisors of his or her
choice in connection with his or her acceptance of this Option, has received
advice from his or her professional advisors in connection with his or her
acceptance of this Option, understands its meaning and import, and has accepted
this Option freely and without coercion or duress; and (ii) the Participant has
not received and is not relying upon any advice, representations or assurances
made by or on behalf of the Company or any Affiliate or any employee of or
counsel to the Company or any Affiliate regarding any tax or other effects or
implications of this Option, the Shares subject to this Option or other matters
contemplated hereby.

The Participant agrees that the Company may withhold from the Participant’s
remuneration, if any, the statutory or contractual amount of any federal,
provincial, state, local and personal income taxes, wage tax and social security
contributions (including, as applicable, UK National Insurance Contributions of
any kind and Canada Pension Plan contributions) required by law or contract to
be withheld or that the Participant has elected to bear (including, as
applicable, employer National Insurance Contributions) in relation to the grant
or exercise of this Option (“Participant Tax Liability”) and, as a condition to
the grant or exercise of this Option (as applicable), the Participant shall make
arrangements satisfactory to the Company to enable it to satisfy all such
withholding requirements. Without limiting the generality of the foregoing, at
the Company’s discretion, the amount required to be withheld may be withheld in
cash from such remuneration. The Participant further agrees that, to the extent
the Company does not withhold an amount from the Participant’s remuneration
sufficient to satisfy the Company’s income or wage tax and social security
withholding obligation, the Participant will reimburse the Company on demand, in
cash, for the amount under-withheld.

2.            WAIVER OF RIGHTS ON TERMINATION (EXCEPT FRANCE, PORTUGAL, SPAIN
AND DENMARK)

The Participant hereby waives all and any rights to compensation or damages in
consequence of the termination of his or her office or employment with the
Company or his or her employing entity for any reasons whatsoever (whether
lawful or unlawful and including, without prejudice to the generality of the
foregoing, in circumstances giving rise to a claim for wrongful dismissal)
insofar as those rights arise or may

arise from his or her ceasing to have rights under or being entitled to exercise
this Option as a result of such termination, or from the loss or diminution in
value of any rights or entitlements in connection with the Plan.

The Plan and this Option do not form part of the Participant’s contract of
employment. If the Participant ceases to be employed or engaged by the Company
or any Affiliate for any reason (including as a result of a repudiatory breach
of contract by the Company or its Affiliate), the Participant shall not be
entitled, and by participating in the Plan the Participant shall be deemed
irrevocably to have waived any entitlement, by way of compensation for loss of
employment, breach of contract or otherwise, to any sum or other benefit to
compensate the Participant for any rights or prospective rights under the Plan.
This exclusion applies equally (and without limitation) to any loss arising from
the way in which the discretion is (or is not) exercised under any provision of
the Plan even if the exercise (or non-exercise) of such discretion is, or
appears to be, irrational or perverse and/or breaches, or is claimed to breach
any implied term of the Plan or any other contract between the Participant and
the Participant’s employer. Participation in the Plan and any benefits provided
under it shall not be pensionable nor will they count as pay or remuneration
when calculating salary related benefits (including, but not limited to,
pension).

3.            DATA PRIVACY (IN ADDITION TO SECTION 19 OF THE AGREEMENT) (EXCEPT
ITALY, PORTUGAL AND SPAIN)

(a)          The Participant hereby explicitly and unambiguously consents to the
collection, use and transfer, in electronic or other form, of his or her
personal data as described in the Agreement by and among, as applicable, his or
her employing entity or contracting party and the Company for the exclusive
purpose of implementing, administering and managing his or her participation in
the Plan.

(b)          The Participant acknowledges the following:

(i)           the Company holds certain personal information about the
Participant, including, but not limited to, his or her name, home address and
telephone number, work location and phone number, date of birth, hire date, bank
and payroll details, social security numbers, details of all awards or any other
entitlement to shares awarded, cancelled, exercised, vested, unvested or
outstanding in the Participant’s favor, for the purpose of implementing,
administering and managing the Plan (“Personal Data”);

(ii)          providing or transferring Personal Data to the Company is
necessary and essential to the Participant’s participation in the Plan and that
the Participant’s refusal to provide Personal Data or withdrawal of consent to
the collection, storage or transfer of Personal Data may affect the
Participant’s ability to participate in the Plan since it would be impossible
for the Company to comply with its contractual obligations under the Plan;

(iii)         the Participant’s Personal Data may be transferred to any third
parties assisting in the implementation, administration and management of the
Plan, that these recipients may be located in the Participant’s country or
elsewhere, and that the recipient’s country may have different data privacy laws
and protections than the Participant’s country;

(iv)         the Participant has been informed that the Company shall not
transfer Personal Data from the Participant’s country without requiring the
recipient to comply with the requirements of the General Data Protection
Regulation (as applicable) and applicable data protection laws, and that the
Participant may request a list with the names and addresses of any potential
recipients of the Personal Data by contacting his or her local human resources
representative;

(v)          Personal Data will be held only as long as is necessary to
implement, administer and manage the Participant’s participation in the Plan and
any potential claim made by the Participant in relation to any award; and

(vi)         the Participant may, at any time, exercise the right of access,
rectification and cancelation of the Participant’s personal data, oppose,
request additional information about the storage and processing of Personal Data
or refuse to the further processing of the Personal Data by contacting in
writing the Participant’s local human resources representative (who can be
identified on the Company’s intranet).

ADDITIONAL COUNTRY-SPECIFIC PROVISIONS

AUSTRALIA

Financial product advice:  The Participant acknowledges and agrees that advice
provided by the Company (if any) in relation to this Option is of a general
nature only and does not take into account the objectives, financial situation
or needs of the Participant. The Participant should consider obtaining advice
from a person who is licensed by the Australian Securities and Investments
Commission to give such advice. The Company is not licensed to provide financial
product advice in Australia in relation to options and there is no cooling-off
regime in Australia that applies in respect of the grant of options.

Risk of acquiring and holding Common Stock:  The Participant acknowledges that
there are risks of acquiring and holding Common Stock. Before accepting or
exercising this Option, or acquiring the underlying Shares, the Participant
should satisfy himself or herself that he or she has a sufficient understanding
of these matters and should consider whether Common Stock is a suitable
investment for the Participant, having regard to the investment objectives,
financial circumstances and taxation position of the Participant.

(a)          The price at which Common Stock is quoted on the Nasdaq Global
Select Market may decrease, even to the extent that the price is less than the
price or prices paid for the Shares by the Participant.

(b)          There is no guarantee that an active market in Common Stock will
continue. The number of potential buyers or sellers of Common Stock on the
Nasdaq Global Select Market may vary at any time. This may increase the
volatility of the market price of Common Stock.

(c)          The Company may not pay dividends on Common Stock at any particular
level or at all. If the Company has paid dividends on Common Stock, it may cease
to pay such dividends.

(d)          Holding Common Stock may have tax implications for the Participant
and the tax regime applying to the Participant may change.

Market price of Common Stock:  The Participant could, from time to time,
ascertain the market price of Common Stock in Australian Dollars by obtaining
the market price from the Nasdaq Global Select Market website, the Company’s
website or applicable U.S. publication, and multiplying that market price by a
published exchange rate to convert U.S. Dollars into Australian Dollars.

BELGIUM

Timing and calculation basis of taxation. You are required to accept the offer
of this Option in writing. If this Option is accepted by you on or prior to the
60th day following the offer, you will recognize taxable income on the 60th day
following the date of the offer (date of grant), and you will be required to
include the taxable income within your yearly income tax return covering the
financial year during which occurred the date of grant. You will not be subject
to income tax upon exercise of this Option. The amount of the taxable income is
calculated as a certain percentage of the fair market value of the underlying
shares at the date of the offer. The income will be taxed as compensation income
and subject to income tax and social security contributions.

If this Option is only accepted by you after the 60th day following the date of
the offer, you will not recognize taxable income on the date of grant but upon
exercise, and you will be required to include the taxable income within your
yearly income tax return covering the financial year during which occurred the
exercise of this Option. The amount of taxable income will then be calculated on
the basis of the fair market value of the stock acquired. The income will be
taxed as compensation income and subject to income tax and social security
contributions.

Capital gains on sale. The capital gains on the sale of the stock are not
taxable to the extent you qualify as a Belgian tax resident.

CANADA

Term of Option.  For purposes of Section 2 of the Agreement, “Termination Date”
means the later of: (i) the date that is the last day of any statutory notice
period applicable to the Participant pursuant to applicable employment standards
legislation; and (ii) the date that is designated by the Company or Affiliate to
which the Participant provides services as the last day of the Participant’s
employment, term of office or engagement with the Company or Affiliate (as
applicable); provided, that in the case of termination of employment by
voluntary resignation by the Participant, such date shall not be earlier than
the date notice of resignation was given. For certainty, except only as
expressly required by applicable employment standards legislation, as amended or
replaced, or agreed by the Company, no portion of this Option shall vest
following the Participant’s Termination Date and no period of notice or payment
in lieu of notice in respect of a termination of an office or employment without
Cause shall extend such Termination Date.

Method of Exercising Option.  Payment of the Exercise Price for the Shares with
respect to which this Option is exercised may not be made in either of the forms
described in clause (b) or clause (c) of Paragraph 9 of the Plan.

DENMARK

Danish Stock Option Act.  In accepting this Option, you acknowledge that you
have received an Employer Statement translated into Danish, which is being
provided to comply with the Danish Stock Option Act and which sets out the main
terms of the Plan applying to you. To the extent more favorable to you and
required to comply with the Stock Option Act, the terms set forth in the
Employer Statement, including terms regarding vesting and forfeiture in
connection with termination of your employment will apply to your participation
in the Plan.

Exchange Control Notification.  If you establish an account holding Shares or
cash outside Denmark, you must report the account to the Danish Tax
Administration. The form which should be used in this respect can be obtained
from a local bank. (Please note that these obligations are separate from and in
addition to the obligations described below.)

Securities and Tax Reporting Notification.  You may hold Shares acquired under
the Plan in a safety-deposit account (e.g., a brokerage account) with either a
Danish bank or with an approved foreign broker or bank. If the Shares are held
with a foreign broker or bank, you are required to inform the Danish Tax
Administration about the safety-deposit account. For this purpose, you must file
a Form V (Erklaering V) with the Danish Tax Administration. Both you and the
broker or bank must sign the Form V. By signing the Form V, the broker or bank
undertakes an obligation, without further request each year, to forward
information to the Danish Tax Administration concerning the Shares in the
safety-deposit account. In the event that the applicable broker or bank with
which the account is held does not wish to, or pursuant to the laws of the
country in question, is not allowed to assume such obligation to report, you
will be solely responsible for providing certain details regarding the foreign
brokerage or bank account and any Shares acquired in connection with the Plan
and held in such account to the Danish Tax Administration as part of your annual
income tax return. By signing the Form V, you authorize the Danish Tax
Administration to examine the account. A sample of the Form V can be found at
the following website: www.skat.dk.

In addition, if you open a brokerage account or a bank account with a U.S. bank,
the account will be treated as a deposit account because cash can be held in the
account. Therefore, you must also file a Form K (Erklaering K) with the Danish
Tax Administration. Both you and the broker must sign the Form K. By signing the
Form K, the broker or bank, as applicable, undertakes an obligation, without
further request each year, to forward information to the Danish Tax
Administration concerning the content of the deposit account. In the event that
the applicable financial institution (broker or bank) with which the account is
held does not wish to, or pursuant to the laws of the country in question, is
not allowed to assume such obligation to report,

you will be solely responsible for providing certain details regarding the
foreign brokerage or bank account to the Danish Tax Administration as part of
your annual income tax return. By signing the Form K, you authorize the Danish
Tax Administration to examine the account. A sample of Declaration K can be
found at the following website: www.skat.dk.

FRANCE

Language Consent.  By accepting the grant, you confirm that you have read and
understood the documents relating to the grant (the Plan, the Grant Notice and
the Agreement, including this Appendix) which were provided in the English
language. You confirm that you are fluent in English, written and spoken. You
accept the terms of these documents accordingly.

Consentement Relatif à la Langue Utilisée.  En acceptant l’attribution,
 vous confirmez avoir lu et compris les documents relatifs à l’attribution (le
Plan, l’Avis et le Contrat, y compris cette Annexe) qui ont été communiqués en
langue anglaise. Vous acceptez les termes de ces documents en connaissance de
cause.

Tax Notification.  This Option is not intended to qualify for favorable tax or
social security treatment in France.

Exchange Control Notification.  If you hold Shares outside of France or maintain
a foreign bank account, you are required to report such to the French tax
authorities when filing your annual tax return.

GERMANY

Taxes.  The following provision supplements Section 1 of this Appendix A:

For the avoidance of doubt, under Section 1 of this Appendix A (which replaces
Section 8 of the Agreement), the Company, inter alia, has the authority to
deduct or withhold, or require the Participant to remit to the Company, an
amount sufficient to satisfy applicable taxes (including wage taxes
(Lohnsteuern), solidarity surcharges (Solidaritätszuschläge), church taxes
(Kirchensteuern) and social security contributions
(Sozialversicherungsbeiträge)) arising from or relating to the (i) the grant,
vesting or exercise of this Option or (ii) the delivery of the Shares. For the
avoidance of doubt, Section 1 of this Appendix A shall remain unaffected.

ITALY

Data Privacy.  The following provision replaces Section 3 of this Appendix A:

You understand that the Company and/or any Affiliate may hold certain personal
information about you, including, without limitation, your name, home address
and telephone number, date of birth, social insurance or other identification
number, salary, nationality, job title, any Shares or directorships held in the
Company or an Affiliate, details of all options, or any other entitlement to
Shares awarded, canceled, exercised, vested, unvested or outstanding in your
favor, for the exclusive purpose of implementing, managing, and administering
the Plan (“Data”) and in compliance with applicable laws and regulations.

You also understand that providing the Company with Data is necessary for the
performance of the Plan and that your refusal to provide such Data would make it
impossible for the Company to perform its contractual obligations and may affect
your ability to participate in the Plan. The Controller of personal data
processing is Intercept Pharmaceuticals, Inc., 10 Hudson Yards, 37th Floor, New
York, NY 10001 and pursuant to Art. 6 let. b) and c) of the General Data
Protection Regulation (“GDPR”) and Legislative Decree no. 196/2003, its
representative in Italy.

You understand that Data will not be publicized, but it may be transferred to
the Company’s designated broker/third party administrator for the Plan or such
other stock plan service provider as may be selected by the Company in the
future (any such entity, “Broker”), or other third parties involved in the
management and administration of the Plan. You understand that Data may also be
transferred to the independent

registered public accounting firm engaged by the Company. You further understand
that the Company and its Affiliates will transfer Data amongst themselves as
necessary for the purposes of implementing, administering and managing your
participation in the Plan, and that the Company and/or any Affiliate may each
further transfer Data to third parties assisting the Company in the
implementation, administration and management of the Plan, including any
requisite transfer of Data to the Broker or other third party with whom you may
elect to deposit any Shares acquired under the Plan. Such recipients may
receive, possess, use, retain, and transfer Data in electronic or other form,
for the purposes of implementing, administering, and managing your participation
in the Plan. You understand that these recipients may be located in or outside
the European Economic Area, such as in the United States or elsewhere, and in
locations that might not provide the same level of protection as intended under
Italian data privacy laws. In such case, the Company undertakes to comply with
the applicable privacy law in order to ensure that the recipient meets the same
standards provided by the European Union legislation, implementing appropriate
and suitable safeguards, such as using standard clauses or equivalent safeguard
measures as provided for by Art. 46 of the GDPR and paragraph 7 of Legislative
Decree no. 196/2003. Should the Company exercise its discretion in suspending
all necessary legal obligations connected with the management and administration
of the Plan, it will delete Data as soon as it has completed all the necessary
legal obligations connected with the management and administration of the Plan.

You understand that Data processing related to the purposes specified above
shall take place under automated or non-automated conditions, anonymously when
possible, that comply with the purposes for which Data is collected and with
confidentiality and security provisions, as set forth by applicable laws and
regulations, with specific reference to Art. 6 let. b) and c) of the GDPR and
Legislative Decree no. 196/2003.

The processing activity, including communication, the transfer of Data abroad,
including outside of the European Economic Area, as herein specified and
pursuant to applicable laws and regulations, does not require your consent
thereto, as the processing is necessary to performance of contractual
obligations related to implementation, administration, and management of the
Plan. You understand that, pursuant to Art. 15 of the GDPR and paragraph 7 of
Legislative Decree no. 196/2003, you have the right to, without limitation,
access, delete, update, correct, or terminate, for legitimate reason, the Data
processing. Additionally, you understand that you may exercise the right to
portability, within the limits set forth by Art. 20 of the GDPR.

Furthermore, you are aware that Data will not be used for direct-marketing
purposes. In addition, Data provided can be reviewed and questions or complaints
can be addressed by contacting your local human resources representative.

Grant Document Acknowledgment.  In accepting the grant of this Option, you
acknowledge that you have received a copy of the Plan, the Grant Notice and the
Agreement, including this Appendix, and have reviewed the Plan, the Grant Notice
and the Agreement, including this Appendix, in their entirety and fully
understand and accepts all provisions thereof.

Foreign Asset Reporting Notification.  If you are an Italian resident and,
during any fiscal year, hold investments or financial assets outside of Italy
(e.g., cash, Shares) which may generate income taxable in Italy (or if you are
the beneficial owner of such an investment or asset even if you do not directly
hold the investment or asset), you are required to report such investments or
assets on your annual tax return for such fiscal year (on UNICO Form, RW
Schedule, or on a special form if you are not required to file a tax return).

NORWAY

Securities and Tax Reporting Notification.  You may hold Shares acquired under
the Plan in a safety-deposit account (e.g., a brokerage account) with either a
Norwegian bank or with an approved foreign broker or bank. If the Shares are
held with a foreign broker or bank, you are required to inform the Norwegian Tax
Administration about the safety-deposit account. You do this on forms RF-1088
and RF-1059 in connection with filing your annual tax return (“selvangivelse”).
Shares held with a Norwegian bank will be reported automatically.

PORTUGAL

Language Consent. By accepting the grant of this Option, you confirm that you
have read and understood the documents relating to the grant (the Plan, the
Grant Notice and the Agreement, including this Appendix) which were provided to
you in English language. You confirm that you are fluent in English, written and
spoken. You accept the terms of these documents accordingly.

Grant Document Acknowledgment. In accepting the grant of this Option, you
acknowledge that you have received a copy of the Plan, the Grant Notice and the
Agreement, including this Appendix, and have reviewed the Plan, the Grant Notice
and the Agreement, including this Appendix, in their entirety and fully
understand and accept all provisions thereof.

Tax Reporting Obligation.  If the Shares acquired under the Plan are held with a
foreign broker or bank, you are required to inform the Portuguese Tax
Authorities about the existence of such account. For this purpose, within the
annual submission of your personal income tax return you must file Annex J with
the Portuguese Tax Administration, identifying the account by reference to the
applicable IBAN – International Bank Account Number and BIC - Bank Identifier
Code.

Income arising out of the Plan and/or derived from the Shares is subject to
reporting to the Portuguese Tax Authorities.

Data Privacy.  The following provision replaces Section 3 of this Appendix A:

You understand that the Company holds certain personal information about you,
including, but not limited to, your name, home address and telephone number,
work location and phone number, date of birth, hire date, details of all awards
or any other entitlement to shares awarded, cancelled, exercised, vested,
unvested or outstanding in the Participant’s favor, for the purpose of
implementing, administering and managing the Plan (“Personal Data”).

You understand that the providing or transferring of Personal Data to the
Company is necessary and essential to your participation in the Plan and that
your refusal to provide Personal Data or withdrawal of consent to the
collection, storage or transfer of Personal Data may affect your ability to
participate in the Plan since it would be impossible for the Company to comply
with its contractual obligations under the Plan.

You understand that your Personal Data may be transferred to any third parties
assisting in the implementation, administration and management of the Plan, that
these recipients may be located in the Participant’s country or elsewhere, and
that the recipient’s country may have different data privacy laws and
protections than the Participant’s country.

You were informed that the personal data communicated outside of Portugal will
be protected identically as provided for in Law No. 67/98, of 26 October, and
that you may request a list with the names and addresses of any potential
recipients of the Personal Data by contacting your local human resources
representative.

You authorize the recipients to receive, possess, use, retain and transfer the
Personal Data, in electronic or other form, for the purposes of implementing,
administering and managing your participation in the Plan.

You understand that Personal Data will be held only as long as is necessary to
implement, administer and manage your participation in the Plan and any
potential claim of the Participant.

You understand that you may, at any time, exercise of the right of access,
rectification and cancelation of your personal data, oppose, request additional
information about the storage and processing of Personal Data or refuse or
withdraw the consents herein, in any case without cost, by contacting in writing
your local human resources representative (who can be identified on the
Company’s intranet).

SPAIN

Taxes.  The following provision supplements Section 1 of this Appendix A:

Pursuant to Royal Decree-Law 13/2011 of 16 September (as amended), wealth tax
(Impuesto sobre el Patrimonio) has been temporarily restored in Spain. If the
Participant’s only foreign assets are the Shares and the value of the Shares on
31 December exceeds the specified threshold the Participant will be required to
make a declaration to the Spanish tax authorities between 1 January and 31 March
of the immediately following year. The Participant much declare foreign rights
and assets including (i) ISIN code of Shares; (ii) the name and corporate
domicile of the issuing company; and (iii) the number, class, and value of the
Shares held as of 31 December.

Exchange Controls. The Participant is responsible for complying with exchange
control regulations in Spain. Declaration of the acquisition of Shares for
statistical purposes to the Dirección General de Comercio e Inversiones (DGCI)
of Ministerio de Economía is compulsory (i) if the purchase price exceeds the
specified threshold; (ii) if the investor holds a stake of at least 10 percent
in the Company; or (iii) if the investor belongs to the Company’ s board of
directors. If Participants purchase any Shares through the use of a Spanish
financial institution, the institution will automatically make the declaration
to the DGCI; otherwise the Participant must make the declaration by filing the
appropriate form with the DGCI. The Participant must also declare ownership of
Shares with the DGCI in January of each year.

Data Privacy. The following provisions replace Section 3 of this Appendix A:

The Participant’s personal data will be processed by Intercept Pharmaceuticals,
Inc. (the “Data Controller”) with a corporate domicile at 10 Hudson Yards, 37th
Floor, New York, NY 10001.

The purpose of the processing is to implement the Grant Notice and the Agreement
under the Plan, verify eligibility conditions and develop and perform the
contractual and legal obligations arising thereof. The processing of the
Participant’s personal data is necessary for such purposes and its legal basis
are the execution and development of the contractual relationship and, if
applicable, the compliance with legal duties applicable to the Data Controller.
Personal data will be processed whilst the Participant holds the relevant awards
and, after this, for six years, or, exceptionally, for the period during which
any kind of liability may arise from a legal or contractual obligation
applicable to the Data Controller.

The Participant’s personal data will be transferred outside the European
Economic Area, to the United States, where Intercept Pharmaceuticals, Inc. is
located. A copy of the relevant appropriate safeguards subscribed in order to
carry out such international data transfer can be requested from human
resources. Additionally, the Participant’s personal data may be disclosed only
to those group companies which may have a legal basis for processing this
personal data.

The Participant may exercise his/her right of access, rights to rectification,
erasure, objection, data portability, restriction of processing and any other
right recognized by the applicable regulations from time to time, by sending a
request to human resources. The Participant may also file any claim or request
related to his or her data protection rights with the relevant supervisory
authority. The personal data processed for the purposes described above derives
from the execution of the Participant’s employment agreement or, in case that
the Participant is an independent professional, the relevant services agreement.

UNITED KINGDOM

NIC Joint Election.  Unless the Company permits otherwise, this Option may not
be exercised unless and until the Company (or the employing entity) has received
from the Participant a duly completed joint election with the Company and his or
her employing entity (in the form prescribed by the Company from time to time)
to the effect that the Participant will become liable, so far as permissible by
law, for the whole of employer national insurance contributions which may arise
in connection with this Option and the Shares which may be or are acquired on
the exercise of this Option.

Taxes.  The following provision supplements Section 1 of this Appendix A:

The amount of the Participant Tax Liability may be withheld in cash from such
remuneration. The Participant further agrees that, if the Company does not
withhold an amount from the Participant’s remuneration sufficient to satisfy the
Participant Tax Liability, the Participant will reimburse the Company on demand,
in cash, for the amount under-withheld. Without limiting the foregoing, the
Participant agrees (i) that the Participant shall, promptly upon being requested
to do so by the Company, the Participant’s employer or former employer (as
appropriate), elect (using a form approved by HM Revenue & Customs) that the
whole or any part of the liability for employer National Insurance Contributions
shall be transferred to the Participant; and (ii) to enter into a joint
election, under section 431(1) or 431(2) of the Income Tax (Earnings & Pensions)
Act 2003, in respect of the Shares delivered pursuant to the award, if required
to do so by the Company, the Participant’s employer or former employer, before,
on or within 14 days after any date of delivery of such Shares.