Director and Officer Indemnity Agreement



 Exhibit 10.8.2 

INDEMNITY AGREEMENT 

This Indemnity Agreement, dated as of             , 2010 (this
“Agreement”), is made by and between DT Acceptance Corporation, an Arizona corporation (the “Company”), and
                    (the “the Indemnitee”). 

RECITALS 

A. The Company is aware that competent and experienced persons are increasingly reluctant to serve as directors, officers or agents of
corporations unless they are protected by comprehensive liability insurance or indemnification, due to increased exposure to litigation costs and risks resulting from their service to such corporations, and due to the fact that the exposure
frequently bears no reasonable relationship to the compensation of such directors, officers and other agents. 
 B. The statutes
and judicial decisions regarding the duties of directors and officers are often difficult to apply, ambiguous, or conflicting, and therefore fail to provide such directors, officers and agents with adequate, reliable knowledge of legal risks to
which they are exposed or information regarding the proper course of action to take. 
 C. Plaintiffs often seek damages in such
large amounts and the costs of litigation may be so enormous (whether or not the case is meritorious), that the defense and/or settlement of such litigation are often beyond the personal resources of directors, officers and other agents. 

D. The Company believes that it is unfair for its directors, officers and agents and the directors, officers and agents of its
subsidiaries to assume the risk of huge judgments and other expenses that may occur in cases in which the director, officer or agent received no personal profit and in cases where the director, officer or agent was not culpable. 

E. The Company recognizes that the issues in controversy in litigation against a director, officer or agent of a corporation such as the
Company or its subsidiaries are often related to the knowledge, motives and intent of such director, officer or agent, that the Indemnitee is usually the only witness with knowledge of the essential facts and exculpating circumstances regarding such
matters, and that the long period of time that usually elapses before the trial or other disposition of such litigation often extends beyond the time that the director, officer or agent can reasonably recall such matters and may extend beyond the
normal time for retirement for such director, officer or agent with the result that the Indemnitee, after retirement or in the event of the Indemnitee’s death, the Indemnitee’s spouse, heirs, executors or administrators, may be faced with
limited ability and undue hardship in maintaining an adequate defense, that may discourage such a director, officer or agent from serving in that position. 

F. Based upon their experience as business managers, the Board of Directors of the Company (the “Board”) has concluded
that, to retain and attract talented and experienced individuals to serve as directors, officers and agents of the Company and its subsidiaries and to 

 

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encourage such individuals to take the business risks necessary for the success of the Company and its subsidiaries, it is necessary for the Company to contractually indemnify its directors,
officers and agents and the directors, officers and agents of its subsidiaries, and to assume for itself maximum liability for expenses and damages in connection with claims against such directors, officers and agents in connection with their
service to the Company and its subsidiaries, and has further concluded that the failure to provide such contractual indemnification could result in great harm to the Company and its subsidiaries and the Company’s stockholders. 

G. Sections 10-851, 10-852 and 10-856 of the Arizona Revised Statutes, under which the Company is organized, requires and/or
empowers the Company to indemnify its directors, officers, employees and agents by agreement and to indemnify persons who serve, at the request of the Company, as the directors, officers, employees or agents of other corporations or enterprises.

 H. The Company desires and has requested the Indemnitee to serve or continue to serve as a director, officer or agent of the
Company and/or one or more subsidiaries of the Company free from undue concern for claims for damages arising out of or related to such services to the Company and/or one or more subsidiaries of the Company. 

I. The Indemnitee is willing to serve, or to continue to serve, the Company and/or one or more subsidiaries of the Company, provided that
the Indemnitee is furnished the indemnity provided for herein. 
 AGREEMENT 

NOW, THEREFORE, the parties hereto, intending to be legally bound, hereby agree as follows: 

1. Definitions. 

(a) Agent. For the purposes of this Agreement, “agent” of the Company means any person who is or was a director, officer,
employee or other agent of the Company or a subsidiary of the Company; or is or was serving at the request of, for the convenience of, or to represent the interests of the Company or a subsidiary of the Company as a director, officer, employee or
agent of another foreign or domestic corporation, partnership, joint venture, trust or other enterprise; or was a director, officer, employee or agent of a foreign or domestic corporation that was a predecessor corporation of the Company or a
subsidiary of the Company, or was a director, officer, employee or agent of another enterprise at the request of, for the convenience of, or to represent the interests of such predecessor corporation. 

(b) Expenses. For purposes of this Agreement, “expenses” include all out-of-pocket costs of any type or nature
whatsoever (including, without limitation, all attorneys’ fees and related disbursements), actually and reasonably incurred by the Indemnitee in connection with either the investigation, defense or appeal of a proceeding or establishing or
enforcing a right to indemnification under this Agreement or Sections 10-851, 10-852 and 10-856 of the Arizona Revised Statutes or otherwise; provided, however, that “expenses” shall not

  

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include any judgments, fines, ERISA excise taxes or penalties, or amounts paid in settlement of a proceeding. 

(c) Proceeding. For the purposes of this Agreement, “proceeding” means any threatened, pending, or completed action,
suit or other proceeding, whether civil, criminal, administrative, or investigative. 
 (d) Subsidiary. For purposes of
this Agreement, “subsidiary” means any corporation of which more than 50% of the outstanding voting securities is owned directly or indirectly by the Company, by the Company and one or more other subsidiaries, or by one or more other
subsidiaries. 
 2. Agreement to Serve. the Indemnitee agrees to serve and/or continue to serve as agent of the Company,
at its will (or under separate agreement, if such agreement exists), in the capacity the Indemnitee currently serves as an agent of the Company, so long as the Indemnitee is duly appointed or elected and qualified in accordance with the applicable
provisions of the Bylaws of the Company or any subsidiary of the Company or until such time as the Indemnitee tenders the Indemnitee’s resignation in writing; provided, however, that nothing contained in this Agreement is intended to create any
right to continued employment by the Indemnitee. 
 3. Liability Insurance. 

(a) Maintenance of D&O Insurance. The Company hereby covenants and agrees that, so long as the Indemnitee shall continue to
serve as an agent of the Company and thereafter so long as the Indemnitee shall be subject to any possible Proceeding by reason of the fact that the Indemnitee was an agent of the Company, the Company, subject to Section 3(c), shall promptly
obtain and maintain in full force and effect directors’ and officers’ liability insurance (“D&O Insurance”) in reasonable amounts from established and reputable insurers. In the event the Company is acquired, this
provision shall be fulfilled by the purchase of a six year tail policy of D&O Insurance. At Indemnitee’s request, Company shall arrange for an annual review of the D&O Insurance by a party other than the procuring brokers, and share the
results of that review with Indemnitee. 
 (b) Rights and Benefits. In all policies of D&O Insurance, the Indemnitee
shall be named as an insured in such a manner as to provide the Indemnitee the same rights and benefits as are accorded to the most favorably insured of the Company’s directors, if the Indemnitee is a director; or of the Company’s
officers, if the Indemnitee is not a director of the Company, but is an officer; or of the Company’s key employees, if the Indemnitee is not a director or officer, but is a key employee. 

(c) Notice. The Company shall give prompt notice as required under the D&O Insurance of such claims as may be covered under
such policies and which may be trigger the indemnification or advancement obligations in this Agreement. On request, the Company shall provide to Indemnitee a copy of such notice delivered to the applicable insurers, and on request from Indemnitee
shall provide copies of all subsequent correspondence between the Company and such insurers regarding the claim, in each case substantially concurrently with the delivery or receipt thereof by the Company. 

 

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 (d) Limitation on Required Maintenance of D&O Insurance. Notwithstanding the
foregoing, the Company shall have no obligation to obtain or maintain D&O Insurance if the Company determines in good faith that such insurance is not reasonably available, the premium costs for such insurance are disproportionate to the amount
of coverage provided, the coverage provided by such insurance is limited by exclusions so as to provide an insufficient benefit, or the Indemnitee is covered by similar insurance maintained by a subsidiary of the Company. 

4. Mandatory Indemnification. Subject to Section 9 below, the Company shall indemnify the Indemnitee as follows: 

(a) Third Party Actions. If the Indemnitee is a person who was or is a party or is threatened to be made a party to any proceeding
(other than an action by or in the right of the Company) by reason of the fact that the Indemnitee is or was an agent of the Company, or by reason of anything done or not done by the Indemnitee in any such capacity, the Company shall indemnify the
Indemnitee against any and all expenses and liabilities of any type whatsoever (including, but not limited to, judgments, fines, ERISA excise taxes and penalties, and amounts paid in settlement) actually and reasonably incurred by the Indemnitee in
connection with the investigation, defense, settlement or appeal of such proceeding, provided the Indemnitee acted in good faith and in a manner the Indemnitee reasonably believed to be in or not opposed to the best interests of the Company and its
stockholders, and, with respect to any criminal action or proceeding, had no reasonable cause to believe the Indemnitee’s conduct was unlawful. 

(b) Derivative Actions. If the Indemnitee is a person who was or is a party or is threatened to be made a party to any proceeding
by or in the right of the Company by reason of the fact that the Indemnitee is or was an agent of the Company, or by reason of anything done or not done by the Indemnitee in any such capacity, the Company shall indemnify the Indemnitee against all
expenses actually and reasonably incurred by the Indemnitee in connection with the investigation, defense, settlement, or appeal of such proceeding, provided the Indemnitee acted in good faith and in a manner the Indemnitee reasonably believed to be
in or not opposed to the best interests of the Company and its stockholders; except that no indemnification under this subsection 4(b) shall be made in respect to any claim, issue or matter as to which such person shall have been finally
adjudged to be liable to the Company by a court of competent jurisdiction unless and only to the extent that the court in which such proceeding was brought shall determine upon application that, despite the adjudication of liability but in view of
all the circumstances of the case, such person is fairly and reasonably entitled to indemnity for reasonable expenses that the court shall deem proper pursuant to Section 10-854 of the Arizona Revised Statutes. 

(c) Actions where the Indemnitee is Deceased. If the Indemnitee is a person who was or is a party or is threatened to be made a
party to any proceeding by reason of the fact that the Indemnitee is or was an agent of the Company, or by reason of anything done or not done by the Indemnitee in any such capacity, and if prior to, during the pendency of after completion of such
proceeding the Indemnitee becomes deceased, the Company shall indemnify the Indemnitee’s heirs, executors and administrators against any and all expenses and liabilities of any type whatsoever (including, but not limited to, judgments, fines,
ERISA excise taxes and penalties, and amounts paid in settlement) actually and reasonably incurred to the extent the Indemnitee would have been entitled to indemnification pursuant to Sections 4(a) or 4(b) above were the Indemnitee still alive.

  

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 (d) Limitations. Notwithstanding the foregoing, the Company shall not be obligated to
indemnify the Indemnitee for expenses or liabilities of any type whatsoever (including, but not limited to, judgments, fines, ERISA excise taxes and penalties, and amounts paid in settlement) for which payment is actually made to or on behalf of the
Indemnitee under a valid and collectible insurance policy of D&O Insurance, or under a valid and enforceable indemnity clause, bylaw or agreement. 

(e) Witness. If Indemnitee is subpoenaed to appear as a witness or produce documents, he shall be considered a “party”
to that proceeding under the advancement and indemnification provisions herein, subject to all other restrictions and requirements. 

(f) Taxes. To the extent allowed by law, if any advancement or indemnification is subject to taxes to be paid by Indemnitee, then
Company agrees to advance or indemnify such tax payments to Indemnitee as an “expense.” Indemnitee will take all reasonable measures to minimize or eliminate such tax liability. 

(g) Investigations. Both formal and so-called informal investigations shall be considered “Proceedings” under the
advancement and indemnification language herein, subject to all other restrictions and requirements. 
 5. Partial
Indemnification. If the Indemnitee is entitled under any provision of this Agreement to indemnification by the Company for some or a portion of any expenses or liabilities of any type whatsoever (including, but not limited to, judgments, fines,
ERISA excise taxes and penalties, and amounts paid in settlement) incurred by the Indemnitee in the investigation, defense, settlement or appeal of a proceeding, but not entitled, however, to indemnification for all of the total amount hereof, the
Company shall nevertheless indemnify the Indemnitee for such total amount except as to the portion hereof to which the Indemnitee is not entitled. 

6. Mandatory Advancement of Expenses. Subject to Section 9(a) below, the Company shall advance all expenses incurred by the
Indemnitee in connection with the investigation, defense, settlement or appeal of any proceeding to which the Indemnitee is a party or is threatened to be made a party by reason of the fact that the Indemnitee is or was an agent of the Company. The
Indemnitee hereby undertakes to repay such amounts advanced only if, and to the extent that, it shall be determined ultimately by final disposition that the Indemnitee is not entitled to be indemnified by the Company as authorized hereby. Such
undertaking shall not be secured and, to the extent allowed by law, shall not be subject to interest. The advances to be made hereunder shall be paid by the Company to the Indemnitee within twenty (20) days following delivery of a written
request therefor by the Indemnitee to the Company, accompanied by invoices received by Indemnitee in connection with such Expenses (but, in the case of invoices in connection with legal services, any references to specific legal work performed or to
expenditures made that would cause Indemnitee to waive any privilege accorded by applicable law shall not be included with the invoice). In the event that the Company fails to pay expenses as incurred by the Indemnitee as required by this paragraph,
the Indemnitee may seek mandatory injunctive relief from any court having jurisdiction to require the Company to pay expenses as set forth in this paragraph. If the Indemnitee seeks mandatory injunctive relief or specific performance pursuant to
this paragraph, it shall not be a defense to enforcement of the 
  

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Company’s obligations set forth in this paragraph that the Indemnitee has an adequate remedy at law for damages or will not suffer irreparable harm, nor shall Indemnitee be required to post
a bond in connection with seeking or obtaining such relief. 
 7. Notice and Other Indemnification Procedures.

 (a) Notice by the Indemnitee. Promptly after receipt by the Indemnitee of notice of the commencement of or the threat
of commencement of any proceeding, the Indemnitee shall, if the Indemnitee believes that indemnification with respect thereto may be sought from the Company under this Agreement, notify the Company of the commencement or threat of commencement
thereof. 
 (b) Notice by Company. If, at the time of the receipt of a notice of the commencement of a proceeding
pursuant to Section 7(a) hereof, the Company has D&O Insurance in effect, the Company shall give prompt notice of the commencement of such proceeding to the insurers in accordance with the procedures set forth in the respective policies.
The Company shall thereafter take all necessary or desirable action to cause such insurers to pay, on behalf of the Indemnitee, all amounts payable as a result of such proceeding in accordance with the terms of such policies. 

(c) Defense. In the event the Company shall be obligated to pay the expenses of any proceeding against the Indemnitee, the
Company, if appropriate, shall be entitled to assume the defense of such proceeding, with counsel approved by the Indemnitee, upon the delivery to the Indemnitee of written notice of its election so to do. After delivery of such notice, approval of
such counsel by the Indemnitee and the retention of such counsel by the Company, the Company will not be liable to the Indemnitee under this Agreement for any fees of counsel subsequently incurred by the Indemnitee with respect to the same
proceeding, provided that (i) the Indemnitee shall have the right to employ the Indemnitee’s counsel in any such proceeding at the Indemnitee’s expense; and (ii) if (A) the employment of counsel by the Indemnitee has been
previously authorized by the Company, (B) the Indemnitee shall have reasonably concluded that there may be a conflict of interest between the Company and the Indemnitee in the conduct of any such defense, or (C) the Company shall not, in
fact, have employed counsel to assume the defense of such proceeding, then the fees and expenses of the Indemnitee’s counsel shall be at the expense of the Company. The Company agrees, to the extent allowed by law, to allocate all defense
expenses, incurred jointly with Indemnitee, solely to the defense of the Company. 
 8. Determination of Right to
Indemnification. 
 (a) Successful Defense. To the extent the Indemnitee has been successful on the merits or
otherwise in defense of any proceeding (including, without limitation, an action by or in the right of the Company) to which the Indemnitee was a party by reason of the fact that the Indemnitee is or was an agent of the Company at any time, the
Company shall indemnify the Indemnitee against all expenses of any type whatsoever actually and reasonably incurred by the Indemnitee in connection with the investigation, defense or appeal of such proceeding. 

 

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 (b) Other Situations. In the event that Section 8(a) is inapplicable, the
Company shall also indemnify the Indemnitee unless, and except to the extent that, the Company shall prove by clear and convincing evidence in a forum listed in Section 8(c) below that the Indemnitee has not met the applicable standard of
conduct required to entitle the Indemnitee to such indemnification. 
 (c) Selection of Forum. The Indemnitee shall be
entitled to select the forum in which the validity of the Company’s claim under Section 8(b) hereof that the Indemnitee is not entitled to indemnification will be heard from among the following: 

(i) A quorum of the Board consisting of directors who are not parties to the proceeding for which indemnification is being sought;

 (ii) The stockholders of the Company; 

(iii) Legal counsel selected by the Indemnitee, and reasonably approved by the Board, which counsel shall make such determination in a
written opinion; or 
 (iv) A panel of three arbitrators, one of whom is selected by the Company, another of whom is selected
by the Indemnitee and the last of whom is selected by the first two arbitrators so selected. 
 (d) Submission to Forum.
As soon as practicable, and in no event later than thirty (30) days after written notice of the Indemnitee’s choice of forum pursuant to Section 8(c) above, the Company shall, at its own expense, submit to the selected forum in such
manner as the Indemnitee or the Indemnitee’s counsel may reasonably request, its claim that the Indemnitee is not entitled to indemnification; and the Company shall act in the utmost good faith to assure the Indemnitee a complete opportunity to
defend against such claim. 
 (e) Expenses Related to this Agreement. Notwithstanding any other provision in this
Agreement to the contrary, the Company shall indemnify the Indemnitee against all expenses incurred by the Indemnitee in connection with any hearing or proceeding under this Section 8 involving the Indemnitee and against all expenses incurred
by the Indemnitee in connection with any other proceeding between the Company and the Indemnitee involving the interpretation or enforcement of the rights of the Indemnitee under this Agreement unless (i) a court of competent jurisdiction finds
that each of the claims and/or defenses of the Indemnitee in any such proceeding was frivolous or made in bad faith, or (ii) indemnification is barred by Sections 10-851.D or 10-856.A of the Arizona Revised Statutes. 

9. Exceptions. Any other provision herein to the contrary notwithstanding, the Company shall not be obligated pursuant to the
terms of this Agreement: 
 (a) Claims Initiated by the Indemnitee. To indemnify or advance expenses to the Indemnitee
with respect to proceedings or claims initiated or brought voluntarily by the Indemnitee and not by way of defense, unless (i) such indemnification is expressly required to be made by law, (ii) the proceeding was authorized by the Board,
(iii) such indemnification is provided by the Company, in its sole discretion, pursuant to the powers vested in the Company under Title 10 of the Arizona Revised Statutes or (iv) the proceeding is brought to establish or

  

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enforce a right to indemnification under this Agreement or any other statute or law or otherwise as required under Section 10-852 of the Arizona Revised Statutes; 

(b) Lack of Good Faith. To indemnify the Indemnitee for any expenses incurred by the Indemnitee with respect to any proceeding
instituted by the Indemnitee to enforce or interpret this Agreement, if a court of competent jurisdiction determines that each of the material assertions made by the Indemnitee in such proceeding was not made in good faith or was frivolous; or

 (c) Unauthorized Settlements. To indemnify the Indemnitee under this Agreement for any amounts paid in settlement of a
proceeding unless the Company consents to such settlement, which consent shall not be unreasonably withheld. 
 10.
Non-exclusivity. The provisions for indemnification and advancement of expenses set forth in this Agreement shall not be deemed exclusive of any other rights that the Indemnitee may have under any provision of law, the Company’s
Certificate of Incorporation or Bylaws, the vote of the Company’s stockholders or disinterested directors, other agreements, or otherwise, both as to action in the Indemnitee’s official capacity and to action in another capacity while
occupying the Indemnitee’s position as an agent of the Company, and the Indemnitee’s rights hereunder shall continue after the Indemnitee has ceased acting as an agent of the Company and shall inure to the benefit of the heirs, executors
and administrators of the Indemnitee. 
 11. Enforcement. Any right to indemnification or advances granted by this
Agreement to the Indemnitee shall be enforceable by or on behalf of the Indemnitee in any court of competent jurisdiction if (i) the claim for indemnification or advances is denied, in whole or in part, or (ii) no disposition of such claim
is made within ninety (90) days of request therefor. The Indemnitee, in such enforcement action, if successful in whole or in part, shall be entitled to be paid also the expense of prosecuting the Indemnitee’s claim. It shall be a defense
to any action for which a claim for indemnification is made under this Agreement (other than an action brought to enforce a claim for expenses pursuant to Section 6 hereof, provided that the required undertaking has been tendered to the
Company) that the Indemnitee is not entitled to indemnification because of the limitations set forth in Sections 4 and 9 hereof. Neither the failure of the Company (including its Board of Directors or its stockholders) to have made a
determination prior to the commencement of such enforcement action that indemnification of the Indemnitee is proper in the circumstances, nor an actual determination by the Company (including its Board of Directors or its stockholders) that such
indemnification is improper, shall be a defense to the action or create a presumption that the Indemnitee is not entitled to indemnification under this Agreement or otherwise. 

12. Subrogation. In the event the Company is obligated to make a payment under this Agreement, the Company shall be subrogated to
the extent of such payment to all of the rights of recovery under an insurance policy or any other indemnity agreement covering the Indemnitee, who shall execute all documents required and shall do all acts that may be necessary to secure such
rights and to enable the Company effectively to bring suit to enforce such rights. 
  

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 13. Survival of Rights. 

(a) All agreements and obligations of the Company contained herein shall continue during the period the Indemnitee is an agent of the
Company and shall continue after Indemnitee has ceased to be so, so long as the Indemnitee shall be subject to any possible claim or threatened, pending or completed action, suit or proceeding, whether civil, criminal, arbitrational, administrative
or investigative, by reason of the fact that the Indemnitee was serving in the capacity referred to herein. 
 (b) The Company
shall require any successor to the Company (whether direct or indirect, by purchase, merger, consolidation or otherwise) to all or substantially all of the business or assets of the Company, expressly to assume and agree to perform this Agreement in
the same manner and to the same extent that the Company would be required to perform if no such succession had taken place. 

14. Interpretation of Agreement. It is understood that the parties hereto intend this Agreement to be interpreted and enforced so
as to provide indemnification to the Indemnitee to the fullest extent permitted by law including those circumstances in which indemnification would otherwise be discretionary. This includes, without limitation, retroactive extension of
Indemnitee’s rights to advancement and indemnification for allegations of otherwise qualified acts or omissions that predate this Agreement. In the event of any change after the date of this Agreement in any applicable law, statute or rule
which expands the right of an Arizona corporation to indemnify a member of its Board of Directors or an officer, employee, agent or fiduciary, it is the intent of the parties hereto that Indemnitee shall enjoy by this Agreement the greater benefits
afforded by such change. In the event of any change in any applicable law, statute or rule which narrows the right of an Arizona corporation to indemnify a member of its Board of Directors or an officer, employee, agent or fiduciary, such change, to
the extent not otherwise required by such law, statute or rule to be applied to this Agreement, shall have no effect on this Agreement or the parties’ rights and obligations hereunder. 

15. Severability. If any provision or provisions of this Agreement shall be held to be invalid, illegal or unenforceable for any
reason whatsoever, (i) the validity, legality and enforceability of the remaining provisions of the Agreement (including without limitation, all portions of any paragraphs of this Agreement containing any such provision held to be invalid,
illegal or unenforceable, that are not themselves invalid, illegal or unenforceable) shall not in any way be affected or impaired thereby, and (ii) to the fullest extent possible, the provisions of this Agreement (including, without limitation,
all portions of any paragraph of this Agreement containing any such provision held to be invalid, illegal or unenforceable, that are not themselves invalid, illegal or unenforceable) shall be construed so as to give effect to the intent manifested
by the provision held invalid, illegal or unenforceable and to give effect to Section 14 hereof. 
 16. Modification and
Waiver. No supplement, modification or amendment of this Agreement shall be binding unless executed in writing by both of the parties hereto. No waiver of any of the provisions of this Agreement shall be deemed or shall constitute a waiver of
any other provisions hereof (whether or not similar) nor shall such waiver constitute a continuing waiver. 
  

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 17. Notice. All notices, requests, demands and other communications under this
Agreement shall be in writing and shall be deemed duly given (i) if delivered by hand and receipted for by the party addressee or (ii) if mailed by certified or registered mail with postage prepaid, on the third business day after the
mailing date. Addresses for notice to either party are as shown on the signature page of this Agreement, or as subsequently modified by written notice. 

18. Governing Law. This Agreement shall be governed exclusively by and construed according to the laws of the State of Arizona as
applied to contracts between Arizona residents entered into and to be performed entirely within Arizona. 
 The parties hereto
have entered into this Indemnity Agreement effective as of the date first above written. 
  

			
	 THE COMPANY:

	
	                           
         , an Arizona corporation
		
	By	 	  

		
	Title	 	  

		
	Address	 	  

		 	  

	
	THE INDEMNITEE:
	
	 
	Print Name:	 	
		
	Address	 	  

		 	  

		 	  




 

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