EXHIBIT 10.1

SPLIT DOLLAR LIFE INSURANCE AGREEMENT

 

Policy Number:

Policy Owner:                                                    Venture Bank 

Insured:                                                            

Relationship of Insured to Bank:                          Executive Officer

Effective Date:                                                     , 2007

          THIS AGREEMENT is adopted this ________ day of _______, 200__, by and
between Venture Financial Group, Inc. and Venture Bank (hereinafter the
“Employer”), and ___________________ (the "Executive").

                    INTRODUCTION

         To encourage the Executive to remain an employee of the Employer, the
Employer is willing to divide the death proceeds of a life insurance policy
(hereinafter “Policy(ies)”) on the Executive's life. The Employer will pay life
insurance premiums from its general assets.

AGREEMENT

        The Employer and the Executive hereby agree that the respective rights
and duties of the Executive and the Employer in the above referenced Policy(ies)
and any Replacement Policy(ies) (defined below) shall be pursuant to the terms
set forth below.

Article 1
General Definitions

  The following terms shall have the meanings specified:

          1.1       “Beneficiary” means each designated person, or the estate of
the deceased Executive, entitled to benefits, if any, upon the death of the
Executive determined pursuant to Article 4.

> 1.2       “Beneficiary Designation Form” means the form established from time
> to time by the Employer that

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the Executive completes, signs, and returns to the Employer to designate one or
more Beneficiaries.

        1.3      “Cash Value” has the meaning given in the Policy agreement.
 
        1.4      “Change in Control”. For the purpose of this Agreement, a
Change in Control shall include any of the following (and for the purposes of
this provision, the term "corporation" shall mean both Venture Bank and/or
Venture Financial Group)

                        A.      Change in the Ownership of a Corporation. A
change in the ownership of the corporation occurs on the date that any one
person or persons acting as a group (as defined in IRC 409A), acquires ownership
of stock of the corporation that, together with stock held by such person or
group, constitutes more than fifty percent (50%) of the total fair market value
or total voting power of the stock of such corporation. The acquisition of
additional stock by the same person or group is not considered to cause a change
in the ownership of the corporation.     B.      Change in the Effective Control
of the Corporation. A change in the effective control of the corporation shall
be deemed to occur on either of the following dates:       (i)      The date any
one person, or persons acting as a group acquires (or has acquired during the
twelve (12) month period ending on the date of the most recent acquisition by
such person or group) ownership of stock of the corporation possessing thirty
percent (30%) or more of the total voting power of the stock of such
corporation; or       (ii)      The date a majority of members of the
corporation’s board of directors is replaced during any twelve (12) month period
by directors whose appointment or election is not endorsed by a majority of the
members of the corporation’s board of directors before the date of the
appointment or election.     C.      Change in the Ownership of a Substantial
Portion of the Corporation’s Assets. A change in the ownership of a substantial
portion of a corporation’s assets shall be deemed to occur on the date that any
one person or group acquires (or has acquired during the twelve (12) month
period ending on the date of the most recent acquisition by such person or
persons) assets from the corporation that have a total gross fair market value
equal to or more than forty percent (40%) of the total gross fair market value
of all of the assets of the corporation immediately before such acquisition or
acquisitions. No Change in Control shall result if the assets are transferred to
certain entities controlled directly or indirectly by the shareholders of the
transferring corporation.  

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            For the purpose of this Agreement, transfers made on account of
deaths or gifts, transfers between family members or transfers to a qualified
retirement plan maintained by the Employer shall not be considered in
determining whether there has been a Change in Control.

 

        1.5       “Early Retirement” means the Executive’s Termination of
Employment, for any reason other than for Cause, on or after attaining the age
of fifty-five (55) and after completing at least ten (10) Years of Service.

        1.6       “Existing Policies” means those life insurance policies
specifically referenced in this Agreement.

        1.7       “Insurer” means each life insurance carrier referenced above
or a Replacement Policy carrier.

        1.8       “Net-at-Risk Proceeds” (hereinafter “NAR”) means the amount
which equals the total proceeds of the Policy paid on the insured’s death minus
the Cash Value of the Policy.

        1.9       “Normal Retirement” means the Executive’s Termination of
Employment, for any reason other than for Cause, on or after attaining the age
of sixty-five (65).

        1.10      “Plan Administrator” is defined in Paragraph 13.1.

        1.11      “Policy” means the Existing Policies and Replacement Policies.

        1.12      “Replacement Policy(ies)” means life insurance policies issued
in exchange for Existing Policies.

        1.13       “Termination of Employment”. The term Termination of
Employment shall be interpreted in accordance with the provisions of IRC 409A as
it applies to the term “Separation From Service”. Whether a termination of
employment has occurred is determined based on whether the facts and
circumstances indicate that the Bank and the Executive reasonably anticipate
that no further services will be performed after a certain date or that the
level of bona fide services the employee will perform after such date (whether
as an employee or as an independent contractor) will permanently decrease to no
more than twenty (20%) percent of the average level of bona fide services
performed (as an employee or an independent contractor) over the immediately
preceding 36-month period (or the full period of services to the employer if the
employee has been providing services to the employer less than 36 months). There
shall be no Termination of Employment while the Executive is on military leave,
sick leave or other bona fide leave of absence, as long as such leave does not
exceed six months, or if longer, so long as the individual retains a right to
re-employment with the service recipient under an applicable statute or by
contract.

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        1.14       Years of Service. The term “Years of Service” means the total
number of years in which the Executive has been employed by or in the service of
Employer. For the purposes of this Plan, a year of employment or service shall
be a three-hundred and sixty-five (365) day period (or 366 day period in the
case of a leap year) that for the first year of employment, commences on the
Participant’s date of hire (or engagement) and that, for any subsequent year,
commences on an anniversary of that hiring date.

Article 2
Policy Title, Ownership and Exchange or Replacement of Policies

        2.1     Title and Ownership. Title and ownership of the Policy shall
reside in the Employer for its benefit and for the benefit of the Executive all
in accordance with this Agreement. The Employer alone may, to the extent of its
interest, exercise the right to borrow or withdraw on the Policy’s Cash Value.
If the Employer and the Executive (or assignee, with the consent of the
Executive) mutually agree to exercise the right to increase the coverage under
the Policy, then, in such event, the rights, duties and benefits of the parties
to such increased coverage shall continue to be subject to the terms of this
Agreement.

        2.2     Exchange or Replacement of Policies. Replacement Policies will
be accorded the same treatment under the Agreement as Existing Policies and
shall, in all respects relating to this Agreement replace the Existing Policies
for which they were exchanged. The Executive shall cooperate with Employer in
all exchanges requested by the Employer by providing and promptly returning
signatures as requested by the Employer or Plan Administrator.

Article 3
Division of Death Proceeds

        Subject to Paragraphs 11.1 and 18.1, the division of the death proceeds
of the policy shall be as follows:

        3.1     Death of Participant Prior to Termination of Employment. In the
event the Executive dies prior to Terminating Employment with Employer, then the
Executive’s Beneficiary(ies), designated in accordance with the terms of this
Agreement, hall be entitled to receive death proceeds equal to the lesser of $
______ Dollars ($) or One Hundred Percent (100%) of the NAR.

            The Employer shall be entitled to the remainder of such proceeds,
and the Employer and the Executive (or assignees) shall share in any interest
due on the death proceeds on a pro rata basis as the proceeds due each
respectively bears to the total proceeds, excluding any such interest.

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        3.2     Death Following Early or Normal Retirement. In the event the
Executive dies after Early or Normal Retirement, then the Executive’s
Beneficiary(ies), designated in accordance with the terms of this Agreement,
shall be entitled to receive death
proceeds equal to the lesser of $ ________ Dollars ($) or One Hundred Percent
(100%) of the NAR.

            The Employer shall be entitled to the remainder of such proceeds,
and the Employer and the Executive (or assignees) shall share in any interest
due on the death proceeds on a pro rata basis as the proceeds due each
respectively bears to the total proceeds, excluding any such interest.

        3.3     Death following Termination of Employment. In the event the
Executive dies after Terminating his Employment with the Employer for any
reason, then Executive’s Beneficiary(ies) shall not be entitled to receive any
death benefit pursuant to the terms of this Agreement.

Article 4
Premium Payment Method

        Subject to the Employer’s absolute right to surrender or terminate the
Policy at any time and for any reason subject to Article 11, prior to a Change
in Control, the Employer shall pay an amount equal to the planned premiums and
any other premium payments that might become necessary to keep the Policy in
force.

Article 5
Taxable Benefit

        Annually the Executive will receive a taxable benefit equal to the
assumed cost of insurance as required by the Internal Revenue Service. The
Employer (or its administrator) will report to the Executive the amount of
imputed income each year on Form W-2 or its equivalent.

Article 6
Assignment

        The Executive may not, without the written consent of the Employer,
assign to any individual, trust or other organization, any right, title or
interest in the subject policy nor any rights, options, privileges or duties
created under this Agreement.

Article 7
Beneficiaries

        7.1 Beneficiary. The Executive shall have the right, at any time, to
designate a Beneficiary(ies) to receive any benefits payable under the Agreement
to a Beneficiary upon the death of the Executive. The Beneficiary designated
under this Agreement may be the same as or different from the beneficiary
designation under any other agreement of

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the Employer in which the Executive participates.

        7.2 Beneficiary Designation and Changes Thereto. The Executive shall
designate a Beneficiary by completing and signing the Beneficiary Designation
Form, and delivering it to the Employer or its designated agent. The Executive
shall have the right to change a Beneficiary by completing, signing and
otherwise complying with the terms of the Beneficiary Designation Form and the
Employer’s rules and procedures, as in effect from time to time. Upon the
acceptance by the Employer of a new Beneficiary Designation Form, all
Beneficiary designations previously filed shall be cancelled. The Employer shall
be entitled to rely on the last Beneficiary Designation Form filed by the
Executive and accepted by the Employer prior to the Executive’s death.

        7.3 Acknowledgment. No designation or change in designation of a
Beneficiary shall be effective until received, accepted and acknowledged in
writing by the Employer or its designated agent.

        7.4 No Beneficiary Designation. If the Executive dies without a valid
designation of Beneficiary, or if all designated Beneficiaries predecease the
Executive, then the Executive’s surviving spouse shall be the designated
Beneficiary. If the Executive has no surviving spouse, the benefits shall be
made payable to the personal representative of the Executive's estate.

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

Article 8
Division of the Cash Surrender Value of the Policy

        The Employer shall at all times be entitled to an amount equal to the
Policy’s Cash Value, less any policy loans and unpaid interest or cash
withdrawals previously incurred by the Employer and any applicable surrender
charges. The Cash Value shall be determined as of the date of surrender or death
as the case may be.

Article 9
Rights of Parties Where Policy Endowment or Annuity Election Exists

In the event the policy involves an endowment or annuity element, the Employer’s
right and interest in any endowment proceeds or annuity benefits, on expiration
of the deferment period, shall be determined under the provisions of this

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Agreement by regarding such endowment proceeds or the commuted value of such
annuity benefits as the policy’s cash value. Such endowment proceeds or annuity
benefits shall be considered to be like death proceeds for the purposes of
division under this Agreement.

 

Article 10
Termination of Agreement

        Provided there has not been a Change in Control, Employer may terminate
this Agreement at any time subject to the obligation under Article 11 to give
thirty (30) days written notice to Executive of Executive’s right to exercise
the option under Article 11. This Agreement shall terminate upon surrender,
lapse, or other termination of the Policy by the Employer. Following a Change in
Control, Employer is obligated to maintain the Policy or Replacement Policy by
paying all premiums when due.

 

Article 11
Option Upon Termination of Agreement

        In the event the Employer gives a thirty (30) day written notice to
Executive of its intent to terminate the Policy and this Agreement, prior to the
termination of the Policy by the Employer, the Executive (or assignee) shall
have a thirty (30) day option to receive from the Employer an absolute
assignment of the Policy in consideration of a cash payment to the Employer.
Such cash payment shall be in an amount the greater of:

                                         (A)      The Employer’s share of the
Cash Value of the Policy on the date of such assignment; or     (B)      The
amount of the premiums that have been paid by the Employer prior to the date of
such assignment.  

        If, within said thirty (30) day option period, the Executive fails to
exercise the option by payment of entire cash payment, then the option and this
Agreement shall terminate and all of the Executive’s rights, interest and claims
in the Policy shall terminate. If the Executive dies during the thirty (30) day
option period, the beneficiary shall be entitled to benefits under this
Agreement.

Article 12
Agreement Binding Upon the Parties and Successors

        This Agreement shall bind the Executive and the Employer, their heirs,
successors, personal representatives and assigns. The Employer shall not merge
or consolidate into or with another Employer, or reorganize, or sell
substantially all of its assets to another Employer, firm or person unless such
succeeding or continuing Employer, firm or person agrees to assume and discharge
the obligations of the Employer.

 

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Article 13
Administrative and Claims Provision

        The following provisions are part of this Agreement and are intended to
meet the requirements of the Employee Retirement Income Security Act of 1974
(“ERISA”):

        13.1     Named Fiduciary and Plan Administrator. The named fiduciary and
plan administrator of this Agreement shall be the Employer (“Plan
Administrator”) until the Board of Directors of Employer designates a different
named fiduciary and plan administrator. As Plan Administrator, the Employer
shall be responsible for the management, control, and administration of the plan
established by this Agreement. The Plan Administrator may delegate to others
certain aspects of the management and operation responsibilities of the plan,
including the employment of advisors and the delegation of any ministerial
duties to qualified individuals.

        13.2     Funding Policy. Subject to the Employer’s absolute right to
surrender or terminate the Policy at any time and for any reason, the funding
policy for this Plan shall be for the Employer to maintain the Policy in force
by paying, when due, all premiums required.

        13.3     Basis of Payment of Benefits. Direct payment by the insurer of
the Policy of death benefit proceeds under the Policy is the basis of payment of
benefits under this Agreement. The insurer’s payment of those benefits is
conditioned on payment of premiums on the Policy.

        13.4     Claims Procedure. In the event a dispute arises over benefits
under this Agreement and Executive’s Beneficiary(ies) believe they are entitled
to receive such benefits, then a written claim must be made to the Plan
Administrator named above within forty-five (45) days from the date payments are
refused. The Plan Administrator shall review the written claim and if the claim
is denied, in whole or in part, shall provide the Beneficiary(ies) in writing
within forty-five (45) days of receipt of such claim the specific reasons for
such denial, reference to the provisions of this Agreement upon which the denial
is based and any additional material or information necessary to perfect the
claim. Such written notice shall further indicate the additional steps to be
taken by claimants if a further review of the claim denial is desired. A claim
shall be deemed denied if the Plan Administrator fails to take any action within
the aforesaid forty-five (45) day period.

        If claimants desire a second review they shall notify the Plan
Administrator in writing within forty-five (45) days of the first claim denial.
Claimants may review this Agreement or any documents relating thereto and submit
any written issues and comments it may feel appropriate. In its sole discretion,
the Plan Administrator shall then review the second claim and provide a written
decision within forty-five (45) days of receipt of such claim. This decision
shall likewise state the specific reasons for the

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decision and shall include reference to specific provisions of the Agreement
upon which the decision is based.

        13.5     Arbitration of Disputes. All unresolved claims, disputes and
other matters in question arising out of or relating to this Agreement or the
breach or interpretation thereof, other than those matters which are to be
determined by the Employer in its sole and absolute discretion, shall be
resolved by binding arbitration before a representative member, selected by the
mutual agreement of the parties, of the Judicial Arbitration and Mediation
Services, Inc. ("JAMS"), located in Seattle, Washington. In the event JAMS is
unable or unwilling to conduct the arbitration provided for under the terms of
this Paragraph, or has discontinued its business, the parties agree that a
representative member, selected by the mutual agreement of the parties, of the
American Arbitration Association ("AAA"), located in Seattle, Washington, shall
conduct the binding arbitration referred to in this Paragraph. Notice of the
demand for arbitration shall be filed in writing with the other party to this
Agreement and with JAMS (or AAA, if necessary). In no event shall the demand for
arbitration be made after the date when institution of legal or equitable
proceedings based on such claim, dispute or other matter in question would be
barred by the applicable statute of limitations. The arbitration shall be
subject to such rules of procedure used or established by JAMS, or if there are
none, the rules of procedure used or established by AAA. Any award rendered by
JAMS or AAA shall be final and binding upon the parties, and as applicable,
their respective heirs, beneficiaries, legal representatives, agents, successors
and assigns, and may be entered in any court having jurisdiction thereof. The
obligation of the parties to arbitrate pursuant to this clause shall be
specifically enforceable in accordance with, and shall be conducted consistently
with, the provisions of Title 9 of Part 3 of the Washington Code of Civil
Procedure. Any arbitration hereunder shall be conducted in Lacey, Washington,
unless otherwise agreed to by the parties

Article 14
Gender and Singular/Plural

        Whenever in this Agreement words are used in the masculine, feminine or
neuter gender, they shall be read and construed as in the masculine, feminine or
neuter gender, whenever they should so apply. Furthermore, wherever applicable,
a singular item shall be interpreted as referring to plural, and visa versa.

Article 15
Insurance Employer Not a Party to This Agreement

        The Insurer shall not be deemed a party to this Agreement, but will
respect the rights of the parties as herein developed upon receiving an executed
copy of this Agreement. Payment or other performance in accordance with the
policy provisions shall fully discharge the Insurer from any and all liability.

Article 16
Amendment or Revocation and Exchange of Policy

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        16.1     Subject to the Employer’s absolute right to surrender or
terminate the Policy at any time and for any reason prior to a Change in
Control, subject to Article 11, during the Executive’s lifetime, this Agreement
may be amended or revoked at any time or times, in whole or in part, by the
mutual written consent of the Executive and the Employer.

        16.2     Notwithstanding the foregoing, the Employer may amend or
terminate this Agreement at any time if, pursuant to legislative, judicial or
regulatory acts, continuation of this Agreement would result in significant
financial penalties, adverse accounting treatments, or other significant
detrimental ramifications to the Employer (other then the financial impact of
splitting the life insurance death benefits). The Employer may, unilaterally and
without the consent of the Executive, exchange any life insurance policy(ies)
that are the subject matter of this Agreement, with or without replacing said
policy(ies) and, in the event of a same or similar exchange, the Executive
expressly agrees to the same.

Article 17
Severability and Interpretation

        If a provision of this Agreement is held to be invalid or unenforceable,
the remaining provisions shall nonetheless be enforceable according to their
terms. Further, in the event that any provision is held to be overbroad as
written such provision shall be deemed amended to narrow its application to the
extent necessary to make the provision enforceable according to law and enforced
as amended.

Article 18
Effect of the Life Insurance Policy’s Contestability Clauses

        18.1     The parties herein understand and agree that the payment of the
benefits provided herein are subject to the Policy’s suicide and contestability
clauses and other such clauses, and if such clauses preclude the Insurer from
paying the full death proceeds, then, in such event, no death benefits of
whatever nature shall be payable to Beneficiary(ies) under this Agreement.

        18.2     IF THE EMPLOYER DOES NOT RECEIVE THE FULL DEATH PROCEEDS FROM
THE INSURER THROUGH NO FAULT OF THE EMPLOYER, THE EMPLOYER HAS NO DUTY TO PAY
ANY FUNDS TO THE EXECUTIVE OR HIS BENEFICIARY(IES) EXCEPT TO THE EXTENT THAT
DEATH PROCEEDS ARE RECEIVED BY THE EMPLOYER FROM THE INSURER.

Article 19
Miscellaneous

        19.1     No Guarantee of Employment. This Agreement is not an employment
policy or contract. It does not give the Executive the right to remain an
employee of the

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Employer, nor does it interfere with the Employer’s right to discharge the
Executive. It also does not require the Executive to remain an employee nor
interfere with the Executive's right to terminate employment at any time.

        19.2     Applicable Law. The Agreement and all rights hereunder shall be
governed by and construed according to the laws of the State of Washington,
except to the extent preempted by the laws of the United States of America.

        19.3     Notice. Any notice, consent or demand required or permitted to
be given under the provisions of this Agreement by one party to another shall be
in writing, shall be signed by the party giving or making the same, and may be
given either by delivering the same to such other party personally, or by
mailing the same, by United States certified mail, postage prepaid, to such
party, addressed to his or her last known address as shown on the records of the
Employer. The date of such mailing shall be deemed the date of such mailed
notice, consent or demand.

        19.4     Entire Agreement. This Agreement constitutes the entire
agreement between the Employer and the Executive as to the subject matter hereof
. No rights are granted to the Executive by virtue of this Agreement other than
those specifically set forth herein.

        IN WITNESS WHEREOF, the Executive and the Employer consent to this
Agreement on the date above written.

 

EXECUTIVE:

EMPLOYER: VENTURE BANK

    ________________________________ By ________________________________
Signature       Title ________________________________

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BENEFICIARY DESIGNATION FORM

     

FOR THE SPLIT DOLLAR LIFE INSURANCE AGREEMENT

I. PRIMARY DESIGNATION         (You may refer to the beneficiary designation
information prior to completion of this form.)   A. Person(s) as a Primary
Designation:           (Please indicate the percentage for each beneficiary.)  
    Name___________________________________

Relationship ___________________ / _______%

 
Address:_______________________________________________________________________________
    (Street)   (City) (State)

(Zip)

  Name___________________________________

Relationship ___________________/_______%

 
Address:_______________________________________________________________________________
    (Street)   (City) (State)

(Zip)

  Name___________________________________

Relationship ___________________ / _______ %

  Address:
_______________________________________________________________________________
    (Street)   (City) (State)

(Zip)

  Name___________________________________

Relationship ___________________ / _______%

 
Address:_______________________________________________________________________________
    (Street)   (City) (State)

(Zip)

  B. Estate as a Primary Designation:        
     My Primary Beneficiary is The Estate of _____________________________ as
set forth in the last will and testament
      dated the day of  _____________, and any codicils thereto.   C. Trust as a
Primary Designation:           Name of the Trust:
____________________________________________________________     Execution Date
of the Trust: _____ / _____ / _________     Name of the Trustee:    
Beneficiary(ies) of the Trust (please indicate the percentage for each
beneficiary)    
_______________________________________________________________________________
   
_______________________________________________________________________________
    Is this an Irrevocable Life Insurance Trust? ________ Yes ________ No    
(If yes and this designation is for a Split Dollar agreement, an Assignment of
Rights form should be completed.)

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II.      SECONDARY (CONTINGENT) DESIGNATION   A.      Person(s) as a Secondary
(Contingent) Designation:

    (Please indicate the percentage for each beneficiary.)      
Name___________________________________

Relationship ___________________ / _______%

 
Address:_______________________________________________________________________________
    (Street)   (City) (State)

(Zip)

  Name___________________________________

Relationship ___________________/_______%

 
Address:_______________________________________________________________________________
    (Street)   (City) (State)

(Zip)

  Name___________________________________

Relationship ___________________ / _______ %

  Address:
_______________________________________________________________________________
    (Street)   (City) (State)

(Zip)

  Name___________________________________

Relationship ___________________ / _______%

 
Address:_______________________________________________________________________________
    (Street)   (City) (State)

(Zip)

B.      Estate as a Secondary (Contingent) Designation:    

My Secondary Beneficiary is The Estate of  _____________________________________
as set forth in my last will and testament dated the _____ day of ___________,
_____ and any codicils thereto.

C.      Trust as a Secondary (Contingent) Designation:

Name of the Trust: ____________________________________________________________
Execution Date of the Trust: _____ / _____ / _________ Name of the Trustee:
____________________________________________________________ Beneficiary(ies) of
the Trust (please indicate the percentage for each beneficiary)
_______________________________________________________________________________
_______________________________________________________________________________

All sums payable under the Split Dollar Life Insurance Agreement by reason of my
death shall be paid to the Primary Beneficiary(ies), if he or she survives me,
and if no Primary Beneficiary(ies) shall survive me, then to the Secondary
(Contingent) Beneficiary(ies). This beneficiary designation is valid until the
participant notifies the bank in writing.

 __________________________  _________________   Executive Date  

NOTE*** IF YOU RESIDE IN A COMMUNITY PROPERTY STATE (ARIZONA, CALIFORNIA, IDAHO,
LOUISIANA, NEVADA, NEW MEXICO, TEXAS, WASHINGTON OR WISCONSIN), AND YOU ARE
DESIGNATING A

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BENEFICIARY OTHER THAN YOUR SPOUSE, THEN YOUR SPOUSE MUST ALSO SIGN THE
BENEFICIARY DESIGNATION FORM.
 

I am aware that my spouse, the above named Insured has designated someone other
than me to be the beneficiary and waive any rights I may have to the proceeds of
such insurance under applicable community property laws. I understand that this
consent and waiver supersedes any prior spousal consent or waiver under this
plan.

Spouse Signature: ______________________________
        Date: _________________

Witness (other than insured) : ___________________________

 

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