Exhibit 10.19.8
OLD DOMINION FREIGHT LINE, INC.
PHANTOM STOCK AWARD AGREEMENT
THIS PHANTOM STOCK AWARD AGREEMENT (the “Agreement”) is made effective as of the
____ day of ________________, 2012 (the “Grant Date”), between Old Dominion
Freight Line, Inc., a Virginia corporation (the “Company”), and
__________________________ (the “Executive”). This Agreement shall be
administered by the Compensation Committee (the “Administrator”) of the Board of
Directors (the “Board”) of the Company or a designee of the Compensation
Committee.
R E C I T A L S:
In consideration of the services of the Executive and such other good and
valuable consideration, the receipt and sufficiency of which are hereby
acknowledged, the Company and the Executive, intending to be legally bound,
hereby agree as follows:
ARTICLE 1.    AWARD. The Company hereby grants to the Executive pursuant to the
Agreement, as a matter of separate inducement and agreement in connection with
his employment with the Company, and not in lieu of any salary or other
compensation for his services (the “Award”), a total of ________ shares of
Phantom Stock (the “Phantom Stock”), subject to the terms, restrictions, and
other conditions of this Agreement. The shares of Phantom Stock awarded to the
Executive shall be credited to a Phantom Stock account to be maintained on
behalf of the Executive. The account shall be debited by the number of shares of
Phantom Stock with respect to which any payments are made pursuant to ARTICLE 3.

ARTICLE 2.    VESTING. Subject to the provisions of this ARTICLE 2, the Award
shall vest on the first to occur of the following: (i) (date of retirement),
provided that the Executive is employed by the Company on such date; (ii) the
date of a Change of Control; (iii) the date of the Executive's death while
employed by the Company; or (iv) the date of the Executive's Total Disability.

If the Award is not vested upon the date of the Executive's termination of
employment with the Company, the Award shall be forfeited, and no payment shall
be made thereon on the Settlement Date or any time thereafter. Notwithstanding
the foregoing, if the Executive's employment is terminated any time For Cause,
the Executive shall forfeit the Award (even if previously vested) as of the date
of such termination of employment and no payments shall be made thereon on the
Settlement Date or any time thereafter. If the Executive engages in a
Competitive Activity, he shall forfeit the right to receive payments with
respect to the Award as provided in Section 3.3.

ARTICLE 3.    SETTLEMENT OF PHANTOM STOCK.
    
3.1.    Settlement of Award. If the Award is vested on the Settlement Date and
is not otherwise forfeited pursuant to ARTICLE 2, the Award shall become payable
as of the Settlement Date. The Settlement Date shall be earlier of (i) the date
of the Executive's termination of employment for any reason other than death,
Total Disability or For Cause; (ii) the date of the Executive's death while
employed by the Company; or (iii) the date of the Executive's termination of
employment as a result of his Total Disability. On the Settlement Date, the
Executive shall be entitled to receive an amount for each share of Phantom Stock
awarded to such Executive with respect to the vested Award equal to the Fair
Market Value of a share of the common stock of the Company (the “Common Stock”)
on the Settlement Date, less any required withholding. Subject to Sections 3.2
and 3.3 of this Agreement, such amount shall be paid in cash to the Executive in
twenty-four substantially equal monthly installments commencing as of the first
day of the calendar month next following the Settlement Date. In the event an
amount becomes payable pursuant to this ARTICLE 3 on account of the Executive's
termination of employment due to death, or the Executive becomes entitled to
receive an amount pursuant to this ARTICLE 3 and he dies prior to receiving any
or all of the amounts to which he is due, then the amounts payable pursuant to
this ARTICLE 3 shall be made to the beneficiary or beneficiaries (which may
include individuals, trusts or other legal entities) designated by the Executive
on the form provided by and filed with the Company prior to his death (the
“Beneficiary Designation Form”). If the Executive fails to designate a
beneficiary or fails to file the Beneficiary Designation Form with the Plan
Administrator (as defined in ARTICLE 10) prior to his death, such amounts shall
be made to his estate. If a named beneficiary entitled to receive payments
pursuant to the Beneficiary Designation Form dies at a time when additional
payments still remain to be paid, then and in any such event, such remaining
payments shall be paid to the other primary beneficiary or beneficiaries named
by the Executive who shall then be living or in existence, if any, otherwise to
the contingent beneficiary or beneficiaries named by the Executive who shall
then be living or in existence, if any; otherwise to the estate of the
Executive.

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3.2.    Small Payments. Notwithstanding the provisions of Section 3.1, in the
event the amount to be paid to or on behalf of an Executive pursuant to
Section 3.1 in settlement of the Award shall be less than $12,000, such amount
shall be paid to the Executive or his beneficiary, as the case may be, in a
single lump sum payment within thirty (30) days following the Settlement Date.

3.3.    Engagement in Competitive Activity. In the event the Administrator
determines, in its sole and absolute discretion, that the Executive has engaged
in a Competitive Activity at any time on or after the Settlement Date and during
the period over which payments are being made to him in settlement of the Award
pursuant this ARTICLE 3, all such payments shall immediately cease and the
Executive shall not be entitled to receive any further payments under the
Agreement.

3.4.    Delay in Payment. Notwithstanding anything to the contrary in the
Agreement or in an Executive or Company payment election, the Company may not
make payment based on “separation from service” (as defined under Code Section
409A) to an Executive who, on the date of separation from service is a specified
employee (as defined under Code Section 409A), earlier than six (6) months
following separation from service (or if earlier, upon the specified employee's
death), except as permitted under this provision. This limitation applies
regardless of the Executive's status as a specified employee or otherwise on any
other date including the next specified employee effective date had the
Executive continued to render services through such date. Furthermore, the first
six (6) months of any such payments of deferred compensation that are required
to be paid in installments shall be paid at the beginning of the seventh (7th)
month following the Executive's separation from service. All remaining
installment payments shall be made as would ordinarily have been made under the
provisions of the Agreement. This section does not apply to payments made on
account of a domestic relations order, payments made because of a conflict of
interest, or payment of employment taxes, all as described in Treas. Reg.
§1.409A-3(i)(2)(i).

ARTICLE 4.    NO RIGHT TO CONTINUED EMPLOYMENT. Nothing in this Agreement shall
confer upon the Executive any right to continue in the employment of the Company
or shall interfere with or restrict in any way the rights of the Company, which
are hereby expressly reserved, to terminate the Executive's employment at any
time for any reason whatsoever, with or without cause. The Executive shall not
have any claim or right to be granted the Award.

ARTICLE 5.    NONTRANSFERABILITY OF AWARD. The Award shall not be transferable
(including by pledge or hypothecation) other than by will or the laws of
intestate succession. Any attempt to anticipate, sell, assign, pledge, encumber,
or transfer the Award or any other benefit or right under the Agreement shall
render such Award, benefit or right null and void.

ARTICLE 6.    REPRESENTATIONS AND WARRANTIES OF EXECUTIVE. The Executive
represents and warrants to the Company that:

6.1.    Agrees to Terms of the Agreement. The Executive has received a copy of
the Agreement, has read and understands the terms of the Agreement, and agrees
to be bound by its terms and conditions.

6.2.    Access to Information. The Executive has had access to all information
regarding the Company and its present and prospective business, assets,
liabilities and financial condition that the Executive reasonably considers
important in connection with the Award, and the Executive has had ample
opportunity to ask questions of the Company's representatives concerning such
matters.

6.3.    Understanding of Risks. The Executive is fully aware of: (i) the highly
speculative nature of the future Fair Market Value of the shares of Common
Stock; (ii) the financial hazards involved in a benefit tied to the future Fair
Market Value of the Common Stock; (iii) the qualifications and backgrounds of
the management of the Company; and (iv) the tax consequences of entering into
the Agreement.

6.4.    Tax Consequences. The Company has made no warranties or representations
to the Executive with respect to the tax consequences (including, but not
limited to, income tax consequences) related to the transactions contemplated by
this Agreement, and the Executive is in no manner relying on the Company or its
representatives for an assessment of such tax consequences. The Executive
acknowledges that he has been advised that he should consult with his own
attorney, accountant, and/or tax advisor regarding the decision to enter into
this Agreement and the consequences thereof. The Executive also acknowledges
that the Company has no responsibility to take or refrain from taking any
actions in order to achieve a certain tax result for the Executive.

    

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ARTICLE 7.    MISCELLANEOUS.

7.1.    This Agreement may be executed in one or more counterparts, all of which
taken together will constitute one and the same instrument.

7.2.    Subject to the terms of the Agreement, the Agreement may only be
amended, modified, or waived by a written agreement executed by both of the
parties hereto. Notwithstanding the foregoing, the Administrator shall have
unilateral authority to amend the Agreement (without Executive consent) to the
extent necessary to comply with applicable laws or changes to applicable laws,
rules or regulations (including but in no way limited to Section 409A of the
Internal Revenue Code of 1986, as amended (the “Code”), and related regulations
or other guidance and federal securities laws).

7.3.    The validity, performance, construction, and effect of this Agreement
shall be governed by and construed in accordance with the laws of the State of
North Carolina without regard to the principles of conflicts of laws thereof,
except as superseded by applicable federal law. Any action, special proceeding
or other proceeding with respect to this Agreement shall be brought exclusively
in the federal or state courts of the State of North Carolina, and by execution
and delivery of this Agreement, the Executive and the Company irrevocably
consent to the exclusive jurisdiction of those courts and the Executive hereby
submits to personal jurisdiction in the State of North Carolina. The Executive
and the Company irrevocably waive any objection, including any objection based
on lack of jurisdiction, improper venue or forum non conveniens, which either
may now or hereafter have to the bringing of any action or proceeding in such
jurisdiction in respect to this Agreement or any transaction related hereto.

7.4.    The Agreement constitutes the entire agreement between the parties
hereto with respect to the Award granted herein.

7.5.    The Agreement shall be binding upon and shall inure to the benefit of
the Company, its successors and assigns, and of Executive and Executive's
executors, administrators, personal representatives and beneficiaries.

7.6.    The Executive shall not have any rights of a shareholder solely due to
the grant or settlement of the Award.

7.7.    The authority to construe and interpret this Agreement shall be vested
in the Administrator, and any interpretation of this Agreement by the
Administrator and any decision made by it with respect to this Agreement is
final and binding.

7.8.    Notwithstanding any other provision of the Agreement to the contrary,
the Company may reduce the amount of any payment otherwise payable to or on
behalf of an Executive in settlement of the Award by the amount of any
obligation of the Executive to or on behalf of the Company that is or becomes
due and payable, including without limitation, any obligation arising under the
Sarbanes-Oxley Act of 2002, and the Executive shall be deemed to have consented
to such reduction.

7.9.    Whenever possible, each provision in the Agreement shall be interpreted
in such manner as to be effective and valid under applicable law, but if any
provision of the Agreement shall be held to be prohibited by or invalid under
applicable law, then (i) such provision shall be deemed amended, and to have
contained from the outset such language as shall be necessary, to accomplish the
objectives of the provision as originally written to the fullest extent
permitted by law, and (ii) all other provisions of the Agreement shall remain in
full force and effect.

7.10.    The obligations of the Company to make payments hereunder shall
constitute a liability of the Company to the Executive. Such payments shall be
from the general funds of the Company, and the Company shall not be required to
establish or maintain any special or separate fund, or otherwise to segregate
assets to assure that such payments shall be made, and neither the Executive nor
any other person shall have any interest in any particular asset of the Company
by reason of its obligations hereunder. Nothing contained in the Agreement shall
create or be construed as creating a trust of any kind or any other fiduciary
relationship between the Company and the Executive or any other person. To the
extent that any person acquires a right to receive payments from the Company
hereunder, such right shall be no greater than the right of an unsecured
creditor of the Company.

7.11.    The Company shall have the right to deduct from payment of the Award
any taxes required by law to be withheld from the Executive with respect to such
payment.

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7.12.    The Award shall be subject to the condition that the Award may not be
settled if the Administrator determines that the settlement of the Award may
violate any applicable law, rule or regulation.

7.13.    No rule of strict construction shall be applied against the Company,
the Administrator, or any other person in the interpretation of any of the terms
of the Agreement, the Award, or any rule or procedure established by the
Administrator.

7.14.    In the event of any change in the outstanding shares of Common Stock by
reason of any stock dividend or split, recapitalization, merger, consolidation,
spin-off, reorganization, combination or exchange of shares, or other similar
corporate change, the Administrator shall make such adjustment to the number of
shares of Phantom Stock subject to the Award as may be necessary to prevent
dilution or enlargement of the Award. Such adjustments shall be conclusive and
binding upon all parties concerned.

7.15.    The Agreement shall be binding on the Company and its successors or
assignees and on the Executive and his executors, administrators, personal
representatives and beneficiaries.

ARTICLE 8.    Certain Definitions. In addition to other terms defined herein,
whenever used in the Agreement, the following terms shall have the meanings set
forth below (unless otherwise indicated by the content):

8.1.    “Change of Control” means and will be deemed to have occurred on the
earliest of the following dates:

(a)    the date any person or group of persons (as defined in Section 13(d) and
14(d) of the Securities Exchange Act of 1934) together with its affiliates,
excluding employee benefit plans of the Company, is or becomes (or publicly
discloses that such person or group is or has become), directly or indirectly,
the “beneficial owner” (as defined in Rule 13d-3 promulgated under the
Securities Exchange Act of 1934, as amended) of securities of the Company
representing thirty-five percent (35%) or more of the combined voting power of
the Company's then outstanding voting securities; provided, however, that the
event described in this subparagraph (a) shall not be deemed to be a Change of
Control by virtue of the beneficial ownership, or the acquisition of beneficial
ownership, of voting securities by (i) any employee benefit plan sponsored or
maintained by the Company or by a person controlled by the Company; (ii) any
underwriter (as such term is defined in Section 2(a)(11) of the Securities Act
of 1933) that beneficially owns voting securities temporarily in connection with
an offering of such securities; or (iii) any member of the family of Earl E.
Congdon or John R. Congdon unless David S. Congdon, acting in good faith,
provides written notice to the Company that David S. Congdon believes, and
within twenty (20) business days after the Company's receipt of David S.
Congdon's notice a majority of the independent members of the Board determines,
that the beneficial ownership of voting securities by such family member creates
a substantial threat to corporate policy and effectiveness. For the purpose of
clause (iii) above, “family” means any lineal descendent, including adoptive
relationships, of Earl E. Congdon or John R. Congdon, any spouse of the
foregoing and any trust established by or for the benefit of any of the
foregoing, and “independent” shall have the meaning set forth in the corporate
governance rules of the principal exchange on which the Company's common stock
is listed; or

(b)    the date when, as a result of a tender offer or exchange offer for the
purchase of securities of the Company (other than such an offer by the Company
for its own securities), or as a result of a proxy contest, merger, share
exchange, consolidation or sale of assets, or as a result of any combination of
the foregoing, individuals who at the beginning of any two (2) year period
during the term of the Agreement constitute the Board, plus new directors whose
election or nomination for election by the Company's shareholders is approved by
a vote of at least two-thirds (2/3) of the directors still in office who were
directors at the beginning of such two-year period (“Continuing Directors”),
cease for any reason during such two-year period to constitute at least
two-thirds (2/3) of the members the Board; or

(c)    the effective date of a merger, share exchange or consolidation of the
Company with any other corporation or entity regardless of which entity is the
survivor, other than a merger, share exchange or consolidation which would
result in the voting securities of the Company outstanding immediately prior
thereto continuing to represent (either by remaining outstanding or being
converted into voting securities of the surviving or acquiring entity) at least
sixty percent (60%) of the combined voting power of the voting securities of the
Company or such surviving or acquiring entity outstanding immediately after such
merger or consolidation; or
    
    

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(d)    the effective date of the sale or disposition by the Company of all or
substantially all of the Company's assets.

8.2.    “Competitive Activity” means (i) the Executive's participation in,
engagement by, possession of a financial or other interest in or filling a
position directly or indirectly with (whether individually or as an employee,
agent, partner, shareholder, consultant, or otherwise), any enterprise or
business if such enterprise or business competes with the business of the
Company in any state in which the Company conducts its business; (ii) the
solicitation by the Executive of any other person to engage in any of the
foregoing activities; (iii) the solicitation of any employee of the Company to
leave the employ of the Company, or to do business with any enterprise or
business which competes with the business of the Company; or (iv) the
solicitation of any customer, vendor or supplier of the Company. The ownership
of an interest constituting not more than (2) two percent of the outstanding
debt or equity in a company whose securities are traded on a recognized stock
exchange or traded on the over-the-counter market shall not be deemed financial
participation in a competitor even though that company may be a competitor of
the Company.

8.3.    “Fair Market Value” of a share of Common Stock as of a given date shall
be established in good faith by the Administrator. The Administrator may use in
its discretion (i) the weighted average of the closing prices of a share of
Common Stock (on the principal exchange on which shares of Common Stock are then
trading) on the first, second and third trading days immediately preceding such
date, or (ii) the closing price of a share of Common Stock on such exchange on
the trading day immediately preceding such date, or (iii) any other method as
the Administrator may determine in good faith.

8.4.    “Total Disability” means a condition for which the Executive is
determined to be disabled under the Company's long-term disability plan as in
effect as of the effective date of the Agreement or as the same may be amended
from time to time.

8.5.    “For Cause” means one or more of the following, in each case as
determined by the Administrator in its sole discretion: (i) the Executive's
conviction by a court of competent jurisdiction of, or pleading “guilty” or “no
contest” to, theft, fraud or embezzlement from the Company; (ii) the Executive's
conviction by a court of competent jurisdiction of, or pleading “guilty” or “no
contest” to, a felony which constitutes a crime involving moral turpitude and
results in material harm to the Company; (iii) willful and continued failure by
the Executive to substantially perform his duties on behalf of the Company
(other than any such failure resulting from the Executive's Total Disability)
for a period of at least thirty (30) consecutive days after a written demand for
substantial performance has been delivered to the Executive by the Responsible
Person (as defined below) which specifically identifies the manner in which the
Responsible Person believes that the Executive has not substantially performed
the Executive's duties; (iv) willful misconduct or gross negligence by the
Executive which is injurious to the Company; or (v) any diversion by the
Executive for his personal gain of any clearly viable and significant business
opportunity from the Company (other than with the prior written consent of the
Board). For purposes of this Section 8.5, an act, or failure to act, on the
Executive's part shall not be deemed “willful” if done, or omitted to be done,
by the Executive in good faith and with reasonable belief that the Executive's
act, or failure to act, was in the best interest of the Company, and
“Responsible Person” shall mean the Chief Executive Officer of the Company or
such other executive officer of the Company who is the direct or indirect
supervisor of the Executive.

ARTICLE 9.    COMPLIANCE WITH CODE SECTION 409A. To the extent applicable, the
Company intends that the Agreement comply with Section 409A of the Code, and all
rules, regulations and other similar guidance issued thereunder (“Code Section
409A”). This Agreement shall at all times be interpreted and construed in a
manner to comply with Code Section 409A (including compliance with any
applicable exemptions from Code Section 409A) and, should any provision be found
not in compliance with Code Section 409A, the Company shall execute any and all
amendments to this Agreement deemed necessary and required by the Company's
legal counsel to achieve compliance with Code Section 409A or any applicable
exemption. In no event shall any payment required to be made pursuant to the
Agreement that is considered deferred compensation within the meaning of Code
Section 409A be made to the Executive unless he has incurred a separation from
service (as defined in Code Section 409A). In the event amendments are required
to make this Agreement compliant with Code Section 409A, the Company shall use
its best efforts to provide the Executive with substantially the same benefits
and payments he would have been entitled to pursuant to this Agreement had Code
Section 409A not applied, but in a manner that is compliant with Code Section
409A or any of its exemptions. The manner in which the immediately preceding
sentence shall be implemented shall be the subject of good faith determination
of the Company. In no event shall any payment required to be made pursuant to
the Agreement that is considered deferred compensation within the meaning of
Code Section 409A (and is not otherwise exempt from the provisions thereof) be
accelerated in violation of Code Section 409A. Any payment to a specified
employee that is considered deferred compensation within the meaning of Code
Section 409A (and is not otherwise exempt from the provisions thereof) and is
made as a result of a

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separation from service cannot commence under Code section 409A until the lapse
of six (6) months after a separation from service (or death of the Executive, if
earlier).

ARTICLE 10.    ERISA REQUIREMENTS.

10.1.    Named Fiduciaries. For purposes of the Employee Retirement Income
Security Act of 1974, as amended (“ERISA”), the Administrator will be the Named
Fiduciary and Plan Administrator with respect to the Agreement. The Agreement
shall be administered and the records of the Agreement shall be maintained on
the basis of the plan year. The plan year shall be the twelve month period
ending on December 31 of each year.
10.2.    Claims and Review Procedures. The following claims procedure shall
apply for purposes of the Agreement. The Executive and his assigns (if any) and
the Company and its assigns (individually or collectively, “Claimant”) must
follow the procedures set forth herein.

10.2.1.    Filing a Claim; Notification to Claimant of Decision: The Claimant
shall make a claim in writing in accordance with procedures and guidelines
established from time to time by the Plan Administrator, which claim shall be
delivered to the Plan Administrator. Any claims relating to the settlement of
the Award must be made by the Claimant within the one-year period following his
termination of employment. The Plan Administrator shall review and make the
decision with respect to any claim. If a claim is denied in whole or in part,
written notice thereof shall be furnished to the Claimant within thirty (30)
days after the claim has been filed. Such notice shall set forth:
(i)    the specific reason or reasons for the denial;

(ii)    a specific reference to the provisions of the Agreement on which denial
is based;

(iii)    a description of any additional material or information necessary for
the Claimant to perfect a claim and an explanation of why such material or
information is necessary; and
 
(iv)    an explanation of the procedure for review of the denied claim.

10.2.2.    Procedure for Review: Any Claimant whose claim has been denied in
full or in part may individually, or through the Claimant's duly authorized
representative, request a review of the claim denial by delivering a written
application for review to the Board at any time within sixty (60) days after
receipt by the Claimant of written notice of the denial of the claim. Such
request shall set forth in reasonable detail:
(i)    the grounds upon which the request for review is based and any facts in
support thereof; and
    
(ii)    any issues or comments which the Claimant considers pertinent to the
claim.

Following such request for review, the Board shall fully and fairly review the
decision denying the claim. Prior to the decision of the Board, the Claimant
shall be given an opportunity to review pertinent documents.
10.2.3.    Decision on Review: A decision on the review of a claim denied in
whole or in part shall be made in the following manner:
(i)    The decision on review shall be made by the Board, which shall consider
the application and any written materials submitted by the Claimant in
connection therewith. The Board, in its sole discretion, may require the
Claimant to submit such additional documents or evidence as the Board may deem
necessary or advisable in making such review.

(ii)    The Board shall render a decision upon a review of a denied claim within
sixty (60) days after receipt of a request for review. If special circumstances
(such as the need to hold a hearing on any matter pertaining to the denied
claim) warrant additional time, the decision will be rendered as soon as
possible, but not later than one hundred twenty (120) days after receipt of a
request for review. Written notice of any such extension will be furnished to
the Claimant prior to the commencement of the extension.

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(iii)    The decision on review shall be in writing and shall include specific
reasons for the decision, written in a manner calculated to be understood by the
Claimant, and the specific references to the provisions of the Agreement on
which the decision is based. The decision of the Board on review shall be final
and conclusive upon all persons. If the decision on review is not furnished to
the Claimant within the time limits prescribed in subparagraph (ii) above, the
claim will be deemed denied on review.

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IN WITNESS WHEREOF, the parties have executed this Agreement effective as of the
Grant Date.
OLD DOMINION FREIGHT LINE, INC.
 
 
 
By:
 
 
 
 
 
Name:
 
 
Title:
 
 
 
 
 
EXECUTIVE
 
 
 
Name:
 
 
Address:
 
 
 
 
 
Social Security Number:
 
 

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BENEFICIARY DESIGNATION
OLD DOMINION FREIGHT LINE, INC.
Subject to and in accordance with the provisions of that certain Old Dominion
Freight Line, Inc. Phantom Stock Award Agreement (the “Agreement”) dated as of
_______ __, 2012, by and between Old Dominion Freight Line, Inc. (the
“Company”), and ______________ (the “Executive”), the Executive hereby
designates the following beneficiary(ies) entitled, upon the death of the
Executive, to any amounts payable under the Agreement following his death (the
“death benefit”):
 
 
(A)
Primary Beneficiary(ies): In equal shares to those of the following
beneficiary(ies) who are living or in existence at the Executive's death:

 
 
 
 
 
 
Name
 
Relationship
 
Address
 
 
 
 
 
 
 
 
 
 

 
 
(B)
Contingent Beneficiary(ies): If there is no primary beneficiary living or in
existence at the Executive's death, then in equal shares to those of the
following beneficiary(ies) who are living or in existence at the Executive's
death:

 
 
 
 
 
 
Name
 
Relationship
 
Address
 
 
 
 
 
 
 
 
 
 

****************************************************
This Beneficiary Designation Form supersedes and revokes all beneficiary
designations, if any, previously made by the Executive with respect to the
Agreement but is not intended to, and does not, supersede or revoke any of the
provisions of ARTICLE 3 of the Agreement.
This Beneficiary Designation Form may be changed by executing and delivering a
new designation to the Administrator.

This Beneficiary Designation Form is signed in duplicate, and one executed copy
shall be retained by the Administrator and one shall be retained by the
Executive.
 
 
 
 
 
 
 
 
DATED:
 
 
 
 EXECUTIVE
 
 
 
 
 
 
 
 
 
 
 
 
 
DATED:
 
 
 
ADMINISTRATOR
 
 
 
 
 
 
 
 
By:
 
 

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