Exhibit 10.12


NI HOLDINGS, INC.


 


Time-Based Restricted Stock Unit Agreement
for Named Executive Officers


 


	Name of Participant:  [___________]	Date of Grant: 
	No. of Units Covered:  [___________]	Vesting Commencement Date:  
	 	
        Vesting Dates:

         



 


THIS RESTRICTED STOCK UNIT AGREEMENT (this “Agreement”)
governs the Stock Unit Award granted by NI HOLDINGS, INC., a North Dakota corporation (the “Company”) to the above-named
individual (the “Participant”), in accordance with and subject to the provisions of the Company’s 2017 Stock
and Incentive Plan (the “Plan”). A copy of the Plan has been made available to the Participant. Unless the context
indicates otherwise, capitalized terms that are not defined in this Agreement shall have the meaning set forth in the Plan.


 


I.            Grant
of Restricted Stock Units.


A.       In
accordance with the Plan, and effective as of the Date of Grant specified above, the Company has granted to the Participant the
number of Stock Units specified at the beginning of this Agreement (collectively, the “Restricted Stock Units,” and
each a “Restricted Stock Unit.”). Each Restricted Unit represents the right to receive a share of Common Stock (a “Share”)
and dividend equivalent amounts corresponding to the Share, subject to the terms and conditions of this Agreement and the Plan.


B.       The
Restricted Stock Units granted to the Participant shall be credited to an account in the Participant’s name. This account
shall be a record of book-keeping entries only and shall be utilized solely as a device for the measurement and determination of
the number of Shares to be issued to or in respect of the Participant pursuant to this Agreement. Restricted Stock Units may not
be transferred by the Participant without the Committee’s prior written consent other than by will or the laws of descent
and distribution.


II.            Vesting
of the Shares.


A.       The
Participant’s interest in the Restricted Stock Units shall vest and become non-forfeitable on each of the vesting dates set
forth above (each a “Vesting Date”) if the Participant remains in the continuous employ of the Company or an Affiliate
from the Vesting Commencement Date through each applicable Vesting Date. Except as provided in paragraphs 2(b) through (e) below,
if the Participant’s employment with the Company or an Affiliate is terminated prior to a Vesting Date, any Restricted Stock
Units that remain unvested as of the date of such termination shall be forfeited.


B.       If
the Participant remains in the continuous employ of the Company or an Affiliate from the Vesting Commencement Date until the date
the Participant’s employment is terminated due to Disability or death that occurs before the last Vesting Date, then any
Restricted Stock Units that remain unvested will vest in full and become non-forfeitable as of the date of such termination.


C.       If
the Participant remains in the continuous employ of the Company or an Affiliate from the Vesting Commencement Date until the Participant’s
Retirement Age, then any Restricted Stock Units that remain unvested upon attainment of Retirement Age will cease to be forfeitable
upon the Participant’s subsequent termination of employment for any reason other than Cause; but rather, such Units shall
remain outstanding and continue to “vest” and become payable upon each applicable Vesting Date.



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D.       If
the Participant remains in the continuous employ of the Company or an Affiliate from the Vesting Commencement Date until the Participant
incurs an Involuntary Termination Due to Position Elimination or Reorganization that occurs before the last Vesting Date, then
any Restricted Stock Units that remain unvested will vest in a pro rata number of the Restricted Stock Units. The pro
rata number of Restricted Stock Units that vest shall be determined by multiplying the unvested Restricted Stock Units corresponding
to a particular Vesting Date by a fraction, the numerator of which is the number of full and partial calendar months of the Participant’s
employment with the Company or an Affiliate from the first day of the Vesting Commencement Date to the date of termination, and
the denominator of which is the number of full calendar months from the Vesting Commencement Date to the Vesting Date. A partial
month of service shall count as a full month. 


E.       If
the Participant remains in the continuous employ of the Company or an Affiliate from the Vesting Commencement Date until a Change
in Control that occurs before the last Vesting Date, and the Participant’s Restricted Stock Units are neither assumed nor
substituted or replaced with similar rights (or cash equivalent value thereof), then any Restricted Stock Units that remain unvested
will vest in full and become non-forfeitable upon the Change in Control. If the Participant’s Restricted Stock Units are
assumed (or substituted or replaced with an award of equivalent value), then, in addition to the circumstances described in paragraphs
(a) through (d) above, if the Participant is involuntarily terminated without Cause or resigns for Good Reason within twenty four
(24) months following the Change in Control but prior to a Vesting Date, any Restricted Stock Units (or replacement award) that
remains unvested will vest in full and become non-forfeitable as of the date of such termination.


III.           Issuance
and Settlement.


A.       After
any Restricted Stock Units vest in accordance with Section 2, the Company shall cause to be issued to the Participant, or
to the Participant’s designated beneficiary or estate in the event of the Participant’s death, one Share in payment
and settlement of each vested Restricted Stock Unit, subject to applicable required tax withholding. The Committee shall cause
the Shares issuable in connection with the vesting of any such Restricted Stock Units to be issued as soon as practicable after
vesting, but in all events no later than 30 days after vesting, and the Participant shall have no power to affect the timing
of such issuance. Such issuance shall be evidenced by a stock certificate or appropriate entry on the books of the Company or a
duly authorized transfer agent of the Company and shall be in complete settlement and satisfaction of such vested Restricted Stock
Units.


B.       Notwithstanding
the foregoing, if the Participant has attained or will attain Retirement Age prior to the last Vesting Date under this Agreement,
such Units shall be treated as “deferred compensation” subject to section 409A of the Internal Revenue Code (the “Code”).
In such case, the following special provisions shall apply to the payment of the underlying Shares:


1.       if
any Restricted Stock Units vest and become payable on account of a Change in Control, the Restricted Stock Units shall not become
payable (even though non-forfeitable) unless the Change in Control constitutes a “change in control event” as defined
in Treasury Regulations promulgated under section 409A of the Code; and


2.       if
any Restricted Stock Units vest and become payable on account of the Participant’s (A) Involuntary Termination Due to Position
Elimination or Reorganization or (B) involuntary termination without Cause or resignation for Good Reason on or after a Change
in Control, the Restricted Stock Units shall not become payable (even though non-forfeitable) unless the termination constitutes
a “separation from service” as defined in Treasury Regulations promulgated under section 409A of the Code. In addition,
if the Participant is a Specified Employee, payment on account of separation from service hereunder shall be made as of the date
that is six months following the Participant’s separation from service (or, if earlier, upon the Participant’s death).


C.       The
Participant may elect to satisfy any applicable required tax arising in relation to the Restricted Stock Units by (i) delivering
cash (including check, draft, money order or wire transfer made payable to the order of the Company) or (ii) having the Company
withhold a portion of the Shares otherwise to be delivered having a Fair Market Value equal to the amount of such tax liability
(subject to any limitations required under applicable financial accounting standards to avoid liability accounting for the Award).
In the case of clause (ii), the Company will not deliver to the Participant any fractional Shares (or equivalent cash value) remaining
after reduction for taxes; rather, any remaining fractional Shares will be cancelled without payment.


IV.       Shareholder
Rights. The Restricted Stock Units do not entitle the Participant to any rights of a shareholder of the Company. Notwithstanding
the foregoing, the Participant shall accumulate an unvested right to payment of cash dividend equivalents on the Shares underlying
Restricted Stock Units if cash dividends are declared by the Company on the Shares on or after the Date of Grant. Such dividend
equivalents will be in an amount of cash per Restricted Stock Unit equal to the cash dividend paid with respect to one Share, subject
to applicable required tax withholding. The Participant shall be entitled solely to payment of accumulated dividend equivalents
with respect to the number of Restricted Stock Units equal to the number of Shares that become issuable to the Participant pursuant
to this Agreement. Dividend equivalents will be paid to the Participant as soon as administratively possible following the date
that the Shares are issued to the Participant. The Participant shall not be entitled to dividend equivalents with respect to dividends
declared prior to the Date of Grant. All dividend equivalents accumulated with respect to forfeited Restricted 



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Stock Units shall
also be irrevocably forfeited. As of the date of issuance of Shares underlying Restricted Stock Units, the Participant shall have
all of the rights of a shareholder of the Company with respect to any Shares issued pursuant hereto.


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


A.       “Cause”
means (i) the Participant’s willful conduct that is demonstrably and materially injurious to the Company or an Affiliate,
monetarily or otherwise; (ii) the Participant’s material breach of written agreement between the Participant and the
Company; (iii) the Participant’s breach of the Participant’s fiduciary duties to the Company or an Affiliate;
(iv) the Participant’s conviction of any crime (or entering a plea of guilty or nolo contendre to any crime)
constituting a felony; or (v) the Participant’s entering into an agreement or consent decree or being the subject of
any regulatory order that in any of such cases prohibits the Participant from serving as an officer or director of a company that
has publicly traded securities. A termination of the Participant shall not be for “Cause” unless the decision to terminate
the Participant is set forth in a resolution of the Board to that effect and which specifies the particulars thereof and that is
approved by a majority of the members of the Board (exclusive of the Participant if the Participant is a member of the Board) adopted
at a meeting called and held for such purpose (after reasonable notice to the Participant and an opportunity for the Participant
to be heard before the Board). No act or failure to act by the Participant will be deemed “willful” if it was done
or omitted to be done by the Participant in good faith or with a reasonable belief on the part of the Participant that the action
or omission was in the best interests of the Company or an Affiliate. Any act or failure to act by the Participant based upon authority
given pursuant to a resolution duly adopted by the Board or based on the advice of counsel to the Company shall be conclusively
presumed to be done or omitted to be done by the Participant in good faith and in the best interest of the Company and its Affiliates.


B.       “Change
in Control” means:


1.       the
approval of the shareholders of the Company, and consummation, of (A) any consolidation, merger or statutory share exchange
of the Company with any person in which the surviving entity would not have as its directors at least a majority of the Incumbent
Board and as a result of which those persons who were shareholders of the Company immediately prior to such transaction would not
hold, immediately after such transaction, at least 50% of the Voting Power of the Company then outstanding or the combined voting
power of the surviving entity’s then outstanding voting securities; (B) any sale, lease, exchange or other transfer
in one transaction or series of related transactions substantially all of the assets of the Company; or (C) the adoption of
any plan or proposal for the complete or partial liquidation or dissolution of the Company. For purposes of this Section 5(a),
“Voting Power” when used with reference to the Company shall mean the voting power of all classes and series of capital
stock of the Company now or hereafter authorized; or


2.       the
individuals who, as of the date of this Agreement, are members of the Board of Directors of the Company (the “Incumbent Board”)
cease for any reason to constitute at least a majority of the Board (provided, however, that if the election or nomination for
election by the Company’s shareholders of any new director was approved by a vote of at least a majority of the Incumbent
Board, such new director shall be considered to be a member of the Incumbent Board).


C.       “Disability”
means the Participant has been determined, by a physician selected by the Company and reasonably acceptable to the Participant,
to be unable to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment
that can be expected to result in death or can be expected to last for a continuous period of not less than 12 months.


D.       “Good
Reason” means without the express written consent of the Participant (i) a change in the Participant’s position with
the Company or an Affiliate which results in a material diminution of the Participant’s authority, duties or responsibilities;
(ii) a material reduction by the Company or an Affiliate in the annual rate of the Participant’s base salary; or (iii) a
change in the location of the Participant’s principal office to a different place that is more than fifty miles from the
Participant’s principal office immediately prior to such change. A reduction in the Participant’s rate of annual base
pay shall be material if the rate of annual base salary on any date is less than ninety percent (90%) of the Participant’s
highest rate of annual base pay as in effect on any date in the preceding thirty-six (36) months. Notwithstanding the two preceding
sentences, a change in the Participant’s duties or responsibilities shall not constitute Good Reason, and the Participant
shall not have Good Reason to resign, solely because the Company does not have common shares or other securities that are publicly
traded. A resignation by the Participant shall not be with “Good Reason” unless the Participant gives the Company written
notice specifying the event or condition that the Participant asserts constitutes Good Reason, the notice is given no more than
ninety days after the occurrence of the event or initial existence of the condition that the Participant asserts constitutes Good
Reason and the Company has failed to remedy or cure the event or condition during the thirty day period after such written notice
is given to the Company.


E.       “Involuntary
Termination Due to Position Elimination or Reorganization” means an involuntary termination of the Participant’s employment
by the Company or its Affiliates due to a job elimination, reduction in force, business 



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restructuring or other circumstances the
Committee deems appropriate, in its sole discretion, as qualifying as an Involuntary Termination Due to Position Elimination or
Reorganization.


F.       “Retirement
Age” means the Participant has both attained age sixty (60) and accumulated at least seventy (70) points. The Participant’s
points shall equal the sum of the participant’s age (in years) plus completed full years of employment with the Company and
its Affiliates.


VI.         No
Right to Continued Employment. This Agreement and the grant of the Stock Unit Award do not give the Participant any rights with
respect to continued employment by the Company or an Affiliate. This Agreement and the grant of the Stock Unit Award shall not
interfere with the right of the Company or an Affiliate to terminate the Participant’s employment.


VII.         Change
in Capital Structure. In accordance with the terms of the Plan, the terms of this Agreement and the number and kind of Shares shall
be adjusted as the Board determines to be equitably required in the event the Company effects one or more stock dividends, stock
split-ups, subdivisions or consolidations of shares or other similar changes in capitalization.


VIII.         Governing
Law; Venue. The laws of the State of North Dakota shall govern all matters arising out of or relating to this Agreement including,
without limitation, its validity, interpretation, construction and performance but without giving effect to the conflict of laws
principles that may require the application of the laws of another jurisdiction. Any party bringing a legal action or proceeding
against any other party arising out of or relating to this Agreement may bring the legal action or proceeding in the United States
District Court for the District of North Dakota or in any court of the State of North Dakota sitting in Fargo, North Dakota. Each
party waives, to the fullest extent permitted by law (i) any objection it may now or later have to the laying of venue of
any legal action or proceeding arising out of or relating to this Agreement brought in a court described in the preceding sentence
and (ii) any claim that any legal action or proceeding brought in any such court has been brought in an inconvenient forum.


IX.         Conflicts.
In the event of any conflict between the provisions of the Plan as in effect on the Date of Grant and this Agreement, the provisions
of the Plan shall govern. All references herein to the Plan shall mean the Plan as in effect on the Date of Grant.


X.         Participant
Bound by Plan. The Participant hereby acknowledges that a copy of the Plan has been made available to the Participant and the Participant
agrees to be bound by all of the terms and provisions of the Plan.


XI.         Binding
Effect. Subject to the limitations stated above and in the Plan, this Agreement shall be binding upon the Participant and the Participant’s
successors in interest and the Company and any successors of the Company.


XII.         Recoupment.
The Participant acknowledges and agrees that the Participant’s rights in the Restricted Stock Units, the Shares and any dividends,
dividend equivalents or other distributions paid or payable with respect to the Restricted Stock Units and the Shares are subject
to recoupment or repayment if, and to the extent that, such action is required under applicable law or any Company recoupment or
“clawback” policy.


 


IN WITNESS WHEREOF, the Company and the Participant
have executed this Restricted Stock Unit Agreement as of the date first set forth above.


 


	NI HOLDINGS, INC.	 	[NAME OF PARTICIPANT]
	 	 	 	 	 
	 	 	 	 	 
	By:	 	 	Signature: 	 
	Name:	 	 	Date:	 
	Title: 	 	 	 	 


 









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