Document:

Form of Medium-Term Notes, Series K,

 Exhibit 4.6 

[Face of Note] 

Unless this certificate is presented by an authorized representative of The Depository Trust Company, a New York corporation
(“DTC”), to the Company or its agent for registration of transfer, exchange or payment, and any certificate issued is registered in the name of Cede & Co. or in such other name as requested by an authorized representative
of DTC (and any payment is made to Cede & Co. or such other entity as is requested by an authorized representative of DTC), ANY TRANSFER, PLEDGE OR OTHER USE HEREOF FOR VALUE OR OTHERWISE BY OR TO ANY PERSON IS WRONGFUL inasmuch as the
registered owner hereof, Cede & Co., has an interest herein. 
  

	 CUSIP NO. 94986RL58 
	
FACE AMOUNT: $                   
          

 REGISTERED NO.      

WELLS FARGO & COMPANY 

MEDIUM-TERM NOTE, SERIES K 

Due Nine Months or More From Date of Issue 

Principal at Risk Securities Linked to the Worst Performing of the S&P 500®
Index and 
 the Russell 2000® Index due May 3, 2021 

WELLS FARGO & COMPANY, a corporation duly organized and existing under the laws of the State of Delaware (hereinafter
called the “Company,” which term includes any successor corporation under the Indenture hereinafter referred to), for value received, hereby promises to pay to CEDE & Co., or registered assigns, an amount equal to the
Redemption Amount (as defined below) on the Stated Maturity Date (as defined below), unless this Security is redeemed prior to the Stated Maturity Date as provided below under “Optional Redemption,” and to pay Contingent Coupon Payments
(as defined below) on the Face Amount of this Security to the extent provided herein on the Contingent Coupon Payment Dates specified herein at the Contingent Coupon Rate (as defined below) until the earlier of the Stated Maturity Date and the
Optional Redemption Date (as defined below), if any. The “Initial Stated Maturity Date” shall be May 3, 2021. If the Final Calculation Day (as defined below) is not postponed, the Initial Stated Maturity Date will be the
“Stated Maturity Date.” If the Final Calculation Day is postponed, the “Stated Maturity Date” shall be the later of (i) the Initial Stated Maturity Date and (ii) the third Business Day (as defined below)
after the Final Calculation Day as postponed. 
 “Face Amount” shall mean, when used with respect to this
Security, the amount set forth on the face of this Security as its “Face Amount.” 
 Optional Redemption 

The Company may, at its option, redeem this Security, in whole but not in part, on any Optional Redemption Date (as defined
below) by giving notice to the Holder hereof on or before the 

 
Calculation Day (as defined below) immediately preceding that Optional Redemption Date. If this Security is redeemed, the Holder hereof will receive the Optional Redemption Price (as defined
below) plus a final Contingent Coupon Payment (as defined below), if any, on the applicable Optional Redemption Date. Unless the Company defaults in the payment of the Optional Redemption Price plus the final Contingent Coupon Payment, if any, this
Security will cease to be outstanding on such Optional Redemption Date, no additional Contingent Coupon Payments will be payable on this Security and the Holder hereof will have no further rights under this Security after such Optional Redemption
Date. The “Optional Redemption Price” is equal to the Face Amount of this Security. The “Optional Redemption Dates” shall be the Contingent Coupon Payment Dates (as defined below) following each Calculation Day
scheduled to occur from October 2016 to January 2021, inclusive. 
 Payment of Contingent Coupon Payments, the Redemption Amount and the Optional
Redemption Price 
 On each quarterly Contingent Coupon Payment Date, the Company shall pay a Contingent Coupon
Payment if, and only if, the Closing Level of the Worst Performing Index on the related Calculation Day is greater than or equal to its Threshold Level (as defined below). A “Contingent Coupon Payment,” if payable as provided
herein, shall be equal to the product of (i) the Face Amount of this Security, (ii) the Contingent Coupon Rate, and (iii) 90/360. The “Contingent Coupon Payment Dates” shall be the fourth Business Day following each
Calculation Day, as each such Calculation Day may be postponed as herein provided, provided that the Contingent Coupon Payment Date with respect to the Final Calculation Day will be the Stated Maturity Date. The “Contingent Coupon Rate” is
5.10% per annum. Any Contingent Coupon Payments will be rounded to the nearest cent, with one-half cent rounded upward. 

Any Contingent Coupon Payment so payable, and punctually paid or duly provided for, on any Contingent Coupon Payment Date
will, as provided in the Indenture, be paid to the Person in whose name this Security (or one or more Predecessor Securities) is registered at the close of business on the Regular Record Date for such Contingent Coupon Payment next preceding such
Contingent Coupon Payment Date. The Regular Record Date for a Contingent Coupon Payment Date shall be the date one Business Day prior to such Contingent Coupon Payment Date. 

Any Contingent Coupon Payment not punctually paid or duly provided for will forthwith cease to be payable to the Holder on
such Regular Record Date and may either be paid to the Person in whose name this Security (or one or more Predecessor Securities) is registered at the close of business on a Special Record Date for the payment of such Defaulted Interest to be fixed
by the Trustee, notice whereof shall be given to Holders of Securities of this series not less than 10 days prior to such Special Record Date, or be paid at any time in any other lawful manner not inconsistent with the requirements of any
securities exchange on which the Securities of this series may be listed, and upon such notice as may be required by such exchange, all as more fully provided in the Indenture. 

Payment of any Contingent Coupon Payment on this Security will be made in immediately available funds at the office or agency
of the Company maintained for that purpose in the City of Minneapolis, Minnesota; provided, however, that, at the option of the Company, payment of any Contingent Coupon Payment may be paid by check mailed to the Person entitled thereto at such

  
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Person’s last address as it appears in the Security Register or by wire transfer to such account as may have been designated by such Person. Payments of any Contingent Coupon Payment and the
Redemption Amount or the Optional Redemption Price, as applicable, on this Security at Maturity will be made against presentation of this Security at the office or agency of the Company maintained for that purpose in the City of Minneapolis,
Minnesota and at any other office or agency maintained by the Company for such purpose. Notwithstanding the foregoing, for so long as this Security is a Global Security registered in the name of the Depositary, any payments on this Security will be
made to the Depositary by wire transfer of immediately available funds. 
 Payment of the Redemption Amount or the Optional
Redemption Price, as applicable, and any Contingent Coupon Payments on this Security will be made in such coin or currency of the United States of America as at the time of payment is legal tender for payment of public and private debts. 

Definitions Relating to Redemption Amount, the Optional Redemption Price and Contingent Coupon Payments 

If this Security is not redeemed prior to the Stated Maturity Date as provided above under “Optional Redemption,”
the “Redemption Amount” of this Security will equal: 
  

	 	•	 	 if the Ending Level of the Worst Performing Index on the Final Calculation Day (as defined below) is greater
than or equal to its Threshold Level: the Face Amount; or 

  

	 	•	 	 if the Ending Level of the Worst Performing Index on the Final Calculation Day is less than its Threshold
Level: 

  

													
		 	 	 	Face Amount	  	x	  	Performance Factor of the Worst Performing	 	 	 	
		 	 	 	  	  	Index on the Final Calculation Day	 	 	 	

 All calculations with respect to the Redemption Amount will be rounded to the nearest one hundred-thousandth,
with five one-millionths rounded upward (e.g., 0.000005 would be rounded to 0.00001); and the Redemption Amount will be rounded to the nearest cent, with one-half cent rounded upward. 

“Index” shall mean each of the S&P 500 Index and the Russell 2000® Index. 
 The “Pricing Date” shall mean
April 27, 2016. 
 The “Worst Performing Index” on any Calculation Day will be the Index with the
lowest Performance Factor on that Calculation Day. 
 The “Performance Factor” with respect to an Index on
any Calculation Day is its Closing Level on such Calculation Day divided by its Starting Level (expressed as a percentage). 

  
 3 

 The “Starting Level” with respect to the S&P 500 Index is
2095.15, its Closing Level on the Pricing Date, and with respect to the Russell 2000® Index is 1154.149, its Closing Level on the Pricing Date. 

The “Ending Level” of an Index will be its Closing Level on the Final Calculation Day. 

The “Threshold Level” with respect to the S&P 500 Index is 1047.575, which is equal to 50% of its
Starting Level, and with respect to the Russell 2000® Index is 577.0745, which is equal to 50% of its Starting Level. 

The “Closing Level” with respect to each Index on any Trading Day means the official closing level of that
Index reported by the relevant Index Sponsor on such Trading Day, as obtained by the Calculation Agent on such Trading Day from the licensed third-party market data vendor contracted by the Calculation Agent at such time; in particular, taking into
account the decimal precision and/or rounding convention employed by such licensed third-party market data vendor on such date, subject to the provisions set forth below under “—Market Disruption Events” and “—Discontinuance
of an Index; Alteration of Method of Calculation.” 
 “Index Sponsor” shall mean the sponsor or
publisher of an Index. 
 “Business Day” shall mean a day, other than a Saturday or Sunday, that is neither
a legal holiday nor a day on which banking institutions are authorized or required by law or regulation to close in New York, New York. 

The “Calculation Days” shall be the 27th day of each
January, April, July and October, commencing July 2016 and ending January 2021, and the Final Calculation Day. If any such day is not a Trading Day with respect to either Index, that Calculation Day for each Index will be postponed to the next
succeeding day that is a Trading Day with respect to each Index. A Calculation Day is also subject to postponement due to the occurrence of a Market Disruption Event (as defined below). The “Final Calculation Day” is April 27,
2021. If a Market Disruption Event occurs or is continuing with respect to either Index on any Calculation Day, then such Calculation Day will be postponed for each Index to the first succeeding day that is a Trading Day for each Index and on which
a Market Disruption Event has not occurred and is not continuing for either Index; however, if such first succeeding Trading Day has not occurred as of the eighth day that is a Trading Day for each Index after the originally scheduled Calculation
Day, that eighth day shall be deemed to be the Calculation Day for each Index. If a Calculation Day has been postponed to that eighth day and a Market Disruption Event occurs or is continuing with respect to either Index on that eighth day, the
Calculation Agent will determine the Closing Level of that Index on that day in accordance with the formula for and method of calculating the Closing Level of such Index last in effect prior to commencement of the Market Disruption Event, using the
closing price (or, with respect to any relevant security, if a Market Disruption Event has occurred with respect to such security, its good faith estimate of the value of such security at the Scheduled Closing Time of the Relevant Stock Exchange for
such security or, if earlier, the actual closing time of the regular trading session of such Relevant Stock Exchange) on that day of each security included in such Index. As used herein, “closing price” means, with respect to any
security on any date, the Relevant Stock Exchange traded or quoted price of such 

  
 4 

 
security as of the Scheduled Closing Time of the Relevant Stock Exchange for such security or, if earlier, the actual closing time of the regular trading session of such Relevant Stock Exchange.

 “Calculation Agent Agreement” shall mean the Calculation Agent Agreement dated as of March 18, 2015
between the Company and the Calculation Agent, as amended from time to time. 
 “Calculation Agent” shall
mean the Person that has entered into the Calculation Agent Agreement with the Company providing for, among other things, whether a Contingent Coupon Payment will be made, the Optional Redemption Price, if any, and the Redemption Amount, if any,
which term shall, unless the context otherwise requires, include its successors under such Calculation Agent Agreement. The initial Calculation Agent shall be Wells Fargo Securities, LLC. Pursuant to the Calculation Agent Agreement, the Company may
appoint a different Calculation Agent from time to time after the initial issuance of this Security without the consent of the Holder of this Security and without notifying the Holder of this Security. 

Certain Definitions 
 A
“Trading Day” with respect to an Index means a day, as determined by the Calculation Agent, on which (i) the Relevant Stock Exchanges with respect to each security underlying such Index are scheduled to be open for trading for
their respective regular trading sessions and (ii) each Related Futures or Options Exchange with respect to such Index is scheduled to be open for trading for its regular trading session. 

The “Relevant Stock Exchange” for any security underlying an Index means the primary exchange or quotation
system on which such security is traded, as determined by the Calculation Agent. 
 The “Related Futures or Options
Exchange” for an Index means an exchange or quotation system where trading has a material effect (as determined by the Calculation Agent) on the overall market for futures or options contracts relating to such Index. 

Discontinuance Of An Index; Alteration Of Method Of Calculation 

If an Index Sponsor discontinues publication of an Index, and such Index Sponsor or another entity publishes a successor or
substitute equity index that the Calculation Agent determines, in its sole discretion, to be comparable to such Index (a “Successor Equity Index”), then, upon the Calculation Agent’s notification of that determination to the
Trustee and the Company, the Calculation Agent will substitute the Successor Equity Index as calculated by the relevant Index Sponsor or any other entity for purposes of calculating the Closing Level of such Index on any date of determination. Upon
any selection by the Calculation Agent of a Successor Equity Index, the Company will cause notice to be given to the Holder of this Security. 

In the event that an Index Sponsor discontinues publication of an Index prior to, and the discontinuance is continuing on, a
Calculation Day and the Calculation Agent determines that no Successor Equity Index is available at such time, the Calculation Agent will calculate a substitute Closing Level for such Index in accordance with the formula for and method of
calculating such Index last in effect prior to the discontinuance, but using only those securities that comprised such Index immediately prior to that discontinuance. If a Successor Equity Index is selected or

  
 5 

 
the Calculation Agent calculates a level as a substitute for such Index, the Successor Equity Index or level will be used as a substitute for such Index for all purposes, including the purpose of
determining whether a Market Disruption Event exists. 
 If on a Calculation Day an Index Sponsor fails to calculate
and announce the level of an Index, the Calculation Agent will calculate a substitute Closing Level of such Index in accordance with the formula for and method of calculating such Index last in effect prior to the failure, but using only those
securities that comprised such Index immediately prior to that failure; provided that, if a Market Disruption Event occurs or is continuing on such day with respect to such Index, then the provisions set forth above under the definition of
“Calculation Days” shall apply in lieu of the foregoing. 
 If at any time the relevant Index Sponsor makes
a material change in the formula for or the method of calculating an Index, or in any other way materially modifies such Index (other than a modification prescribed in that formula or method to maintain such Index in the event of changes in
constituent stock and capitalization and other routine events), then, from and after that time, the Calculation Agent will, at the close of business in New York, New York, on each date that the Closing Level of such Index is to be calculated,
calculate a substitute Closing Level of such Index in accordance with the formula for and method of calculating such Index last in effect prior to the change, but using only those securities that comprised such Index immediately prior to that
change. Accordingly, if the method of calculating an Index is modified so that the level of such Index is a fraction or a multiple of what it would have been if it had not been modified, then the Calculation Agent will adjust such Index in order to
arrive at a level of such Index as if it had not been modified. 
 Market Disruption Events 

A “Market Disruption Event” with respect to an Index means any of the following events as determined by the
Calculation Agent in its sole discretion: 
  

	 	(A)	 The occurrence or existence of a material suspension of or limitation imposed on trading by the Relevant Stock
Exchanges or otherwise relating to securities which then comprise 20% or more of the level of such Index or any Successor Equity Index at any time during the one-hour period that ends at the Close of Trading on that day, whether by reason of
movements in price exceeding limits permitted by those Relevant Stock Exchanges or otherwise. 

  

	 	(B)	 The occurrence or existence of a material suspension of or limitation imposed on trading by any Related
Futures or Options Exchange or otherwise in futures or options contracts relating to such Index or any Successor Equity Index on any Related Futures or Options Exchange at any time during the one-hour period that ends at the Close of Trading on that
day, whether by reason of movements in price exceeding limits permitted by the Related Futures or Options Exchange or otherwise. 

  

	 	(C)	 The occurrence or existence of any event, other than an early closure, that materially disrupts or impairs the
ability of market participants in general to effect 

  
 6 

	 	 
transactions in, or obtain market values for, securities that then comprise 20% or more of the level of such Index or any Successor Equity Index on their Relevant Stock Exchanges at any time
during the one-hour period that ends at the Close of Trading on that day. 

  

	 	(D)	 The occurrence or existence of any event, other than an early closure, that materially disrupts or impairs the
ability of market participants in general to effect transactions in, or obtain market values for, futures or options contracts relating to such Index or any Successor Equity Index on any Related Futures or Options Exchange at any time during the
one-hour period that ends at the Close of Trading on that day. 

  

	 	(E)	 The closure on any Exchange Business Day of the Relevant Stock Exchanges on which securities that then
comprise 20% or more of the level of such Index or any Successor Equity Index are traded or any Related Futures or Options Exchange with respect to such Index or any Successor Equity Index prior to its Scheduled Closing Time unless the earlier
closing time is announced by the Relevant Stock Exchange or Related Futures or Options Exchange, as applicable, at least one hour prior to the earlier of (1) the actual closing time for the regular trading session on such Relevant Stock
Exchange or Related Futures or Options Exchange, as applicable, and (2) the submission deadline for orders to be entered into the Relevant Stock Exchange or Related Futures or Options Exchange, as applicable, system for execution at such actual
closing time on that day. 

  

	 	(F)	 The Relevant Stock Exchange for any security underlying such Index or Successor Equity Index or any Related
Futures or Options Exchange fails to open for trading during its regular trading session. 

 For purposes
of determining whether a Market Disruption Event has occurred with respect to an Index: 
  

	 	(1)	 the relevant percentage contribution of a security to the level of such Index or any Successor Equity Index
will be based on a comparison of (x) the portion of the level of such Index attributable to that security and (y) the overall level of such Index or Successor Equity Index, in each case immediately before the occurrence of the Market
Disruption Event; 

  

	 	(2)	 the “Close of Trading” on any Trading Day for such Index or any Successor Equity Index means
the Scheduled Closing Time of the Relevant Stock Exchanges with respect to the securities underlying such Index or Successor Equity Index on such Trading Day; provided that, if the actual closing time of the regular trading session of any such
Relevant Stock Exchange is earlier than its Scheduled Closing Time on such Trading Day, then (x) for purposes of clauses (A) and (C) of the definition of “Market Disruption Event” above, with respect to any security
underlying such Index or Successor Equity Index for which such Relevant Stock Exchange is its Relevant Stock Exchange, the “Close of Trading” means such actual closing time and (y) for purposes of clauses (B) and (D) of the
definition of “Market Disruption Event” above, with 

  
 7 

	 	 
respect to any futures or options contract relating to such Index or Successor Equity Index, the “Close of Trading” means the latest actual closing time of the regular trading session
of any of the Relevant Stock Exchanges, but in no event later than the Scheduled Closing Time of the Relevant Stock Exchanges; 

  

	 	(3)	 the “Scheduled Closing Time” of any Relevant Stock Exchange or Related Futures or Options
Exchange on any Trading Day for such Index or any Successor Equity Index means the scheduled weekday closing time of such Relevant Stock Exchange or Related Futures or Options Exchange on such Trading Day, without regard to after hours or any other
trading outside the regular trading session hours; and 

  

	 	(4)	 an “Exchange Business Day” means any Trading Day for such Index or any Successor Equity Index
on which each Relevant Stock Exchange for the securities underlying such Index or any Successor Equity Index and each Related Futures or Options Exchange with respect to such Index or any Successor Equity Index are open for trading during their
respective regular trading sessions, notwithstanding any such Relevant Stock Exchange or Related Futures or Options Exchange closing prior to its Scheduled Closing Time. 

Calculation Agent 

The Calculation Agent will determine whether a Contingent Coupon Payment will be made, the Optional Redemption Price, if any,
and the Redemption Amount, if any. In addition, the Calculation Agent will (i) determine if adjustments are required to the Closing Level of an Index under the circumstances described in this Security, (ii) if publication of an Index is
discontinued, select a Successor Equity Index or, if no Successor Equity Index is available, determine the Closing Level of such Index under the circumstances described in this Security, and (iii) determine whether a Market Disruption Event has
occurred. 
 The Company covenants that, so long as this Security is Outstanding, there shall at all times be a Calculation
Agent (which shall be a broker-dealer, bank or other financial institution) with respect to this Security. 

All determinations made by the Calculation Agent with respect to this Security will be at the sole discretion of the
Calculation Agent and, in the absence of manifest error, will be conclusive for all purposes and binding on the Company and the Holder of this Security. 

Redemption and Repayment 

This Security is not subject to repayment at the option of the Holder hereof prior to May 3, 2021. This Security is
subject to redemption prior to May 3, 2021 as set forth under “Optional Redemption” above. This Security is not entitled to any sinking fund. 

Acceleration 
 If
an Event of Default, as defined in the Indenture, with respect to this Security shall occur and be continuing, the Redemption Amount (calculated as set forth in the next two sentences) of this Security may be declared due and payable in the manner
and with the effect provided in the 

  
 8 

 
Indenture. The amount payable to the Holder hereof upon any acceleration permitted under the Indenture will be equal to the Redemption Amount hereof calculated as provided herein, plus a portion
of a final Contingent Coupon Payment, if any. The Redemption Amount and any final Contingent Coupon Payment will be calculated as though the date of acceleration were the Final Calculation Day. The final Contingent Coupon Payment, if any, will be
prorated from and including the immediately preceding Contingent Coupon Payment Date to but excluding the date of acceleration. 
  

 

Reference is hereby made to the further provisions of this Security set forth on the reverse hereof, which further provisions
shall for all purposes have the same effect as if set forth at this place. 
 Unless the certificate of authentication
hereon has been executed by the Trustee referred to on the reverse hereof by manual signature or its duly authorized agent under the Indenture referred to on the reverse hereof by manual signature, this Security shall not be entitled to any benefit
under the Indenture or be valid or obligatory for any purpose. 
 [The remainder of this page has been left intentionally blank] 

  
 9 

 IN WITNESS WHEREOF, the Company has caused this instrument to be duly executed
under its corporate seal. 
 DATED:
                                 

 

					
	WELLS FARGO & COMPANY
		
	By:	 	 
		 	Its:	 	 

 [SEAL] 
  

					
	Attest:	 	 
		 	Its:	 	 

  

			
	 TRUSTEE’S CERTIFICATE OF

AUTHENTICATION
 This is one of the Securities of the

series designated therein described
 in the within-mentioned Indenture.

	
	 CITIBANK, N.A.,

      as Trustee

		
	By:	 	 
		 	Authorized Signature
	
	OR
	
	 WELLS FARGO BANK, N.A.,

  as Authenticating Agent for the Trustee

		
	By:	 	 
		 	Authorized Signature

  
 10 

 [Reverse of Note] 

WELLS FARGO & COMPANY 

MEDIUM-TERM NOTE, SERIES K 

Due Nine Months or More From Date of Issue 

Principal at Risk Securities Linked to the Worst Performing of the S&P 500®
Index and the 
 Russell 2000® Index due May 3, 2021 

This Security is one of a duly authorized issue of securities of the Company (herein called the
“Securities”), issued and to be issued in one or more series under an indenture dated as of July 21, 1999, as amended or supplemented from time to time (herein called the “Indenture”), between the Company and
Citibank, N.A., as Trustee (herein called the “Trustee,” which term includes any successor trustee under the Indenture), to which Indenture and all indentures supplemental thereto reference is hereby made for a statement of the
respective rights, limitations of rights, duties and immunities thereunder of the Company, the Trustee and the Holders of the Securities, and of the terms upon which the Securities are, and are to be, authenticated and delivered. This Security is
one of the series of the Securities designated as Medium-Term Notes, Series K, of the Company, which series is limited to an aggregate principal amount or face amount, as applicable, of $25,000,000,000 or the equivalent thereof in one or more
foreign or composite currencies. The amount payable on the Securities of this series may be determined by reference to the performance of one or more equity-, commodity- or currency-based indices, exchange traded funds, securities, commodities,
currencies, statistical measures of economic or financial performance, or a basket comprised of two or more of the foregoing, or any other market measure or may bear interest at a fixed rate or a floating rate. The Securities of this series may
mature at different times, be redeemable at different times or not at all, be repayable at the option of the Holder at different times or not at all and be denominated in different currencies. 

Article Sixteen of the Indenture shall not apply to this Security. 

The Securities are issuable only in registered form without coupons and will be either
(a) book-entry securities represented by one or more Global Securities recorded in the book-entry system maintained by the Depositary or (b) certificated
securities issued to and registered in the names of, the beneficial owners or their nominees. 
 The Company agrees, to the
extent permitted by law, not to voluntarily claim the benefits of any laws concerning usurious rates of interest against a Holder of this Security. 

Modification and Waivers 

The Indenture permits, with certain exceptions as therein provided, the amendment thereof and the modification of the rights
and obligations of the Company and the rights of the Holders of the Securities of each series to be affected under the Indenture at any time by the Company and the Trustee with the consent of the Holders of a majority in principal amount of the
Securities at the 

  
 11 

 
time Outstanding of all series to be affected, acting together as a class. The Indenture also contains provisions permitting the Holders of a majority in principal amount of the Securities of all
series at the time Outstanding affected by certain provisions of the Indenture, acting together as a class, on behalf of the Holders of all Securities of such series, to waive compliance by the Company with those provisions of the Indenture. Certain
past defaults under the Indenture and their consequences may be waived under the Indenture by the Holders of a majority in principal amount of the Securities of each series at the time Outstanding, on behalf of the Holders of all Securities of such
series. Solely for the purpose of determining whether any consent, waiver, notice or other action or Act to be taken or given by the Holders of Securities pursuant to the Indenture has been given or taken by the Holders of Outstanding Securities in
the requisite aggregate principal amount, the principal amount of this Security will be deemed to be equal to the amount set forth on the face hereof as the “Face Amount” hereof. Any such consent or waiver by the Holder of this Security
shall be conclusive and binding upon such Holder and upon all future Holders of this Security and of any Security issued upon the registration of transfer hereof or in exchange herefor or in lieu hereof, whether or not notation of such consent or
waiver is made upon this Security. 
 Defeasance 

Section 403 and Article Fifteen of the Indenture and the provisions of clause (ii) of Section 401(1)(B) of the
Indenture, relating to defeasance at any time of (a) the entire indebtedness on this Security and (b) certain restrictive covenants and certain Events of Default, upon compliance by the Company with certain conditions set forth therein,
shall not apply to this Security. The remaining provisions of Section 401 of the Indenture shall apply to this Security. 
 Authorized
Denominations 
 This Security is issuable only in registered form without coupons in denominations of $1,000 or any
amount in excess thereof which is an integral multiple of $1,000. 
 Registration of Transfer 

Upon due presentment for registration of transfer of this Security at the office or agency of the Company in the City of
Minneapolis, Minnesota, a new Security or Securities of this series, with the same terms as this Security, in authorized denominations for an equal aggregate Face Amount will be issued to the transferee in exchange herefor, as provided in the
Indenture and subject to the limitations provided therein and to the limitations described below, without charge except for any tax or other governmental charge imposed in connection therewith. 

This Security is exchangeable for definitive Securities in registered form only if (x) the Depositary notifies the
Company that it is unwilling or unable to continue as Depositary for this Security or if at any time the Depositary ceases to be a clearing agency registered under the Securities Exchange Act of 1934, as amended, and a successor depositary is not
appointed within 90 days after the Company receives such notice or becomes aware of such ineligibility, (y) the Company in its sole discretion determines that this Security shall be exchangeable for definitive Securities in registered form
and notifies the Trustee thereof or (z) an Event of Default with respect to the Securities represented hereby has occurred and is continuing. If this Security is exchangeable pursuant to the preceding sentence, it shall be exchangeable for
definitive Securities in registered 

  
 12 

 
form, bearing interest at the same rate, having the same date of issuance, Stated Maturity Date and other terms and of authorized denominations aggregating a like amount. 

This Security may not be transferred except as a whole by the Depositary to a nominee of the Depositary or by a nominee of the
Depositary to the Depositary or another nominee of the Depositary or by the Depositary or any such nominee to a successor of the Depositary or a nominee of such successor. Except as provided above, owners of beneficial interests in this Global
Security will not be entitled to receive physical delivery of Securities in definitive form and will not be considered the Holders hereof for any purpose under the Indenture. 

Prior to due presentment of this Security for registration of transfer, the Company, the Trustee and any agent of the Company
or the Trustee may treat the Person in whose name this Security is registered as the owner hereof for all purposes, whether or not this Security be overdue, and neither the Company, the Trustee nor any such agent shall be affected by notice to the
contrary. 
 Obligation of the Company Absolute 

No reference herein to the Indenture and no provision of this Security or the Indenture shall alter or impair the obligation
of the Company, which is absolute and unconditional, to pay the Contingent Coupon Payments, if any, and the Redemption Amount or the Optional Redemption Price, as applicable, on this Security at the times, place and rate, and in the coin or
currency, herein prescribed, except as otherwise provided in this Security. 
 No Personal Recourse 

No recourse shall be had for the payment of any Contingent Coupon Payments or the Redemption Amount or the Optional Redemption
Price, as applicable, on this Security or for any claim based hereon, or otherwise in respect hereof, or based on or in respect of the Indenture or any indenture supplemental thereto, against any incorporator, stockholder, officer or director, as
such, past, present or future, of the Company or any successor corporation, whether by virtue of any constitution, statute or rule of law, or by the enforcement of any assessment or penalty or otherwise, all such liability being, by the acceptance
hereof and as part of the consideration for the issuance hereof, expressly waived and released. 
 Defined Terms 

All terms used in this Security which are defined in the Indenture shall have the meanings assigned to them in the Indenture
unless otherwise defined in this Security. 
 Governing Law 

This Security shall be governed by and construed in accordance with the law of the State of New York, without regard to
principles of conflicts of laws. 

  
 13 

 ABBREVIATIONS 

The following abbreviations, when used in the inscription on the face of this instrument, shall be construed as though they
were written out in full according to applicable laws or regulations: 
  

					
	 TEN COM
	 	  -- 
	 	 as tenants in common

			
	 TEN ENT
	 	  -- 
	 	 as tenants by the entireties

			
	 JT TEN
	 	  -- 
	 	 as joint tenants with right

of survivorship and not
 as
tenants in common

  

									
	 UNIF GIFT MIN ACT
	 	  -- 
	 	 	 	 Custodian
	 	 
		 		 	(Cust)	 		 	(Minor)

  

	
	Under Uniform Gifts to Minors Act
	
	   

	(State)

 Additional abbreviations may also be used though not in the above list. 

FOR VALUE RECEIVED, the undersigned hereby sell(s) and transfer(s) unto 

 

	
	 Please Insert Social Security or
 Other
Identifying Number of Assignee

	
	   

  
  

 
  
  

 
 (PLEASE
PRINT OR TYPE NAME AND ADDRESS INCLUDING POSTAL ZIP CODE OF ASSIGNEE)

  
 14 

 the within Security of WELLS FARGO & COMPANY and does hereby irrevocably constitute and
appoint __________________ attorney to transfer the said Security on the books of the Company, with full power of substitution in the premises. 
 Dated:
                                         
        
  

	
	   

  

	
	   

 NOTICE: The signature to this assignment must correspond with the name as written upon the face of the
within instrument in every particular, without alteration or enlargement or any change whatever. 

  
 15EX-10.1

 Exhibit 10.1 

EXECUTIVE OFFICER EMPLOYMENT AGREEMENT 

This Executive Officer Employment Agreement (this “Agreement”) is being entered into as of February 23, 2016 but effective as of
March 1, 2016 (the “Effective Date”) by and between AMERISAFE, Inc., a Texas corporation with its principal place of business in DeRidder, Louisiana (the “Company”) and Kathryn H. Shirley, a competent individual of the
lawful age of majority who will principally render her services in DeRidder, Louisiana (the “Employee”). 
 WITNESSETH: 

WHEREAS, Employee desires to induce the Company to continue to employ her and Employee desires to continue to engage in an employment
relationship with the Company and the Company desires to induce Employee to continue her employment with the Company and the Company desires to continue an employment relationship with Employee under the specific terms and conditions as set forth
below; 
 NOW, THEREFORE, in exchange for good and valuable consideration, the sufficiency and receipt of which is hereby acknowledged and
in exchange for the mutual covenants and obligations contained in this Agreement, the Company and Employee hereby covenant and agree as follows: 
  

	1.	Employment. 

  

	 	(a)	The Company hereby agrees to employ Employee, and Employee hereby accepts such employment with the Company, for the period set forth in Section 2 hereof, subject to the terms and conditions hereinafter set forth.

  

	 	(b)	Employee affirms and represents that she is under no obligation to any former employer or other person or entity which is in any way inconsistent with, or which imposes any restriction upon, Employee’s employment
hereunder with the Company, the employment of Employee by the Company, or Employee’s undertakings under this Agreement. 

  

	2.	Term of Employment. Unless earlier terminated as provided in this Agreement, the term of Employee’s employment under this Agreement shall be for a period beginning on the Effective Date
and ending on March 1, 2017; provided, however, that this Agreement shall automatically renew for successive one year periods, unless either party shall notify the other in writing not less than thirty (30) days prior to the third anniversary
date or any successive anniversary date that such party does not intent to renew this Agreement. Such period, plus any annual renewal periods, or, if Employee’s employment hereunder is earlier terminated as provided herein and including
termination pursuant to Section 9, or such shorter period, is sometimes referred to herein as the “Employment Term”. 

  

	3.	 Duties. Employee shall be employed by the Company as a senior executive officer of the Company and shall endeavor in good faith to competently
perform such duties as inherent in Employee’s employment or any designated job position or as specified by the Company and shall also perform and discharge such other employment duties and

	 	
responsibilities as the Board of Directors shall from time to time reasonably determine, not inconsistent with Employee’s position as a senior executive officer with the Company. Employee
shall also comply with any By-Laws of the Company, as applicable. Employee shall perform Employee’s duties principally at the offices of the Company at 2301 Highway 190 West, DeRidder, Louisiana, with such travel to such other locations from
time to time as the Board of Directors or the Chief Executive Officer of the Company may reasonably request. Except as may otherwise be approved in advance by the Board of Directors of the Company, and except during vacation periods and reasonable
periods of absence due to sickness, injury or disability, Employee shall devote Employee’s full time throughout the Employment Term to the services required of Employee hereunder; provided that the foregoing shall not prohibit Employee from
engaging in reasonable charitable, civic, and community activities. Employee shall render Employee’s business services exclusively to the Company and its subsidiaries and affiliate entities during the Employment Term and shall use her good
faith efforts, judgment and energy to improve and advance the business and interests of the Company and its subsidiaries in a manner consistent with the duties of Employee’s position. Employee shall diligently, prudently, professionally, and
responsibly perform her duties and shall discharge her employment utilizing her best faith efforts and prudent judgment with a high degree of proficiency and competency and for the exclusive interest of the Company. 

 

	4.	General Compliance, Code of Ethics and Conflicts of Interest. 

  

	 	(a)	Employee shall comply with all applicable laws and regulations (federal, state and local) and shall comply with all applicable directives, orders, and regulations of any governmental agency or regulatory body including
federal, state, and local agencies and bodies. Employee shall also comply with all policies and procedures of the Company and directives of the Board of Directors. Employee understands, acknowledges and agrees that she holds a position of trust and
that fiduciary duties and responsibilities may apply under applicable law and that these duties and responsibilities may be continuing in nature, even after separation from employment. Employee agrees to fully and faithfully perform and discharge
all such duties, responsibilities, and obligations. 

  

	 	(b)	Employee has an obligation to act in an ethical manner in dealings with the Company, with co-employees, with customers and any third party. In this regard, Employee is required to be honest, forthright and to not take
any action or make statements or engage in any conduct which is unethical, improper or which could create the appearance of impropriety. In addition, Employee shall not engage in any conduct, take any actions or make statements which negatively
reflect upon Company or in any way harm or potentially cause harm to the Company’s image, reputation or good will. 

  

	 	(c)	 Employee must also ensure that she does not engage in any conflict of interest. In this regard, Employee shall not engage in any activity or conduct
which is contrary to the exclusive interests of or in conflict with the exclusive interests of the Company. All business opportunities presented to Employee during the course 

  
 2 

	 	
and scope of her employment or while employed with the Company are to be used for the benefit of the Company only. Further, Employee shall not take any position contrary to the Company’s
interests or inconsistent with Employee’s employment with the Company. 

  

	5.	EEO Compliance. Employee shall not engage in any conduct which constitutes or which may be considered an unlawful employment practice or which violates or could violate any employment practices, equal employment
opportunity, discrimination, or retaliation laws or regulations (federal, state, or local). Employee acknowledges that the Company is an Equal Opportunity Employer and prohibits all forms of unlawful discrimination in the terms and condition of
employment, it prohibits all forms of harassment, including sexual harassment, and it prohibits retaliation against any employee who engages in protected activity. 

 

	6.	Salary and Bonus. 

  

	 	(a)	Salary. As compensation for the services to be performed by the Employee hereunder during the Employment Term, the Company shall pay the Employee a base salary at the annual rate of not less than Two Hundred Ten
Thousand and No/100s Dollars ($210,000) (said amount, together with any increases thereto as may be determined from time to time by the Compensation Committee of the Board of Directors of the Company (the “Committee”) in its sole
discretion, being hereinafter referred to as “Salary”). Any Salary payable hereunder shall be paid in regular intervals in accordance with the Company’s established and regular payroll practices from time to time in effect, but in no
event less than monthly. 

  

	 	(b)	Bonus. Employee shall be eligible to receive bonus compensation from Company for each fiscal year (or portion thereof) occurring during the Employment Term in amounts, if any, as may be determined by the
Committee in its sole discretion, which may include performance-based criteria or annual incentive plans to be established from time to time by such Committee in its sole discretion, provided that any such Bonus so awarded shall be paid in the
calendar year following the year in which the services for which such Bonus is awarded were performed. 

  

	 	(c)	Long-Term Incentive Awards. Employee will be eligible to receive long-term incentive awards for each fiscal year occurring during the Employment Term, in amounts and subject to the terms and conditions,
which may include performance-based criteria, as determined by the Committee in its sole discretion. 

  

	 	(d)	Withholding and Taxes. The payment of any Salary, Bonus, long-term incentive awards and the payment of any separation pay pursuant to this Agreement, shall be subject to applicable withholding and payroll taxes,
and such other deductions as may be required under the Company’s employee benefit plans. 

  
 3 

	7.	Other Benefits. 

 During the Employment Term, Employee shall: 

 

	 	(a)	be eligible to participate in all employee fringe benefits and pension, retirement or profit sharing plans that may be provided by the Company for its other senior executive officers in accordance with the provision of
any such plans, as the same may be in effect from time to time; 

  

	 	(b)	be eligible to participate in all medical and health plans or other employee welfare benefit plans that may be provided by the company for its other senior executive officers in accordance with the provisions of any
such plans, as the same be in effect from time to time; 

  

	 	(c)	be entitled to at least 23 vacation/personal days in each calendar year; Employee shall also be entitled to all paid holidays given by the Company to its other senior executive officers; 

 

	 	(d)	be entitled to sick pay and disability benefits in accordance with any Company policy that may be applicable to other senior executive officers from time to time; 

 

	 	(e)	be entitled to a car allowance consistent with established Company practices as of the date hereof and which may be in effect from time to time; 

 

	 	(f)	be entitled to accrue earned and unused vacation time and carry such unused time forward from year to year during the Employment Term, provided the amount of accrued and unused time shall not exceed 200 hours at any
time during the term hereof; and 

  

	 	(g)	be entitled to reimbursement for all reasonable and authorized out-of-pocket business expenses incurred by Employee in the performance of Employee’s duties hereunder in accordance with Company policies and
practices that may be applicable to senior executive officers from time to time, provided that such business expenses shall be reimbursed, if at all, not later than the year following that in which such expenses are incurred, and that the amount of
expenses eligible for reimbursement during one taxable year may not affect the amount of expenses eligible for reimbursement in another taxable year. 

  

	8.	Confidential Information. Employee hereby covenants, agrees and acknowledges as follows: 

  

	 	(a)	 Employee has and will have access to and will participate in the development of or be acquainted with confidential and proprietary information and
trade secrets that directly or indirectly relate to the business, prospects, operations and other aspects of the Company and any other present or future subsidiaries and affiliates of the Company (collectively with the Company, the
“Companies”), including but not limited to (1) customer lists; the identity, lists or descriptions of new or 

  
 4 

	 	
prospective customers; financial statements; cost reports or other financial information; contract proposals or bidding information, business plans; training and operations methods and manuals;
personnel records; software programs; reports and correspondence; and management systems, policies or procedures, including related forms and manuals; (2) information pertaining to future developments such as future marketing or acquisition plans or
ideas; and (3) all other tangible and intangible property, which are used in the business and operations of the Companies but not made public. The information and trade secrets relating to the business of the Companies described hereinabove in this
paragraph 8(a) are hereinafter referred to collectively as the “Confidential Information”, provided that the term “Confidential Information” shall not include any information (x) that is or becomes publicly available (other than
as a result of violation of this Agreement by the Employee), or (y) that Employee receives or received on a non-confidential basis from a source (other than the Companies or any of their representatives) that is not prohibited from disclosing such
information by a legal, contractual or fiduciary obligation (provided, however that the Employee shall not be deemed to be in violation of this clause 8(a)(y) unless she has actual knowledge of any such obligation on the party of any such source).
“Confidential Information” also includes, but is in no way limited to: financial information, budgets, general plans, business plans, data, trade secrets, computer software, technical information, research and development, product and
service information, processes, insured lists, insured information, renewal and expiration dates, pricing and underwriting information, processes, procedures and standards, sales information, marketing information, bid information, job or project
information, contracts, purchasing information, data processing, formulas, designs, drafts, drawings, systems, specifications, means, techniques, compilations, intellectual property, inventions, developments and improvements, operational methods,
protocols, business strategies, market information, vendor or supplier information, personnel matters and records and matters that are sensitive, business, proprietary and confidential information. “Confidential Information” also includes,
but is in no way limited to, any other proprietary, confidential or business information or documentation which is protected by or which is otherwise defined as trade secrets under any federal or state trade secret laws including, but in no way
limited to, Louisiana’s Uniform Trade Secrets Act (La.R.S. 51:1431, et seq.) or other applicable law. 

  

	 	(b)	Employee agrees that she will not use, disclose, communicate, disseminate or otherwise make known, directly or indirectly, any Confidential Information to any person or entity not employed by or directly affiliated with
the Company. Additionally, Employee agrees that she will not use any Confidential Information for the benefit of herself or for the benefit of any other person or entity that is not employed by or affiliated with the Company or in any way that may
be directly or indirectly competitive with or detrimental to the interests of the Company. 

  

	 	(c)	 In the event that Employee receives an order or subpoena from a court of competent jurisdiction and venue or an order or subpoena from a governmental
agency with jurisdiction and authority, Employee shall, within forty-eight (48) 

  
 5 

	 	
hours of receipt of such order or subpoena, immediately notify, by telephone communication and in writing, the Company’s Chief Executive Officer and Employee shall provide the Company’s
Chief Executive Officer with a copy of any such order or subpoena and Employee shall notify Company’s Chief Executive Officer of whether or not she intends to comply with the order or subpoena and Employee shall cooperate with the Company in
any action it takes in order to protect its rights or to contest or dispute the disclosure of Confidential Information pursuant to such order or subpoena. 

  

	 	(d)	Employee acknowledges and agrees that a remedy at law for any breach or threatened breach of the provisions of this Section 8 would be inadequate and, therefore, agrees that the Company shall be entitled to injunctive
relief in addition to any other available rights and remedies in case of any such breach or threatened breach; provided, however, that nothing contained herein shall be construed as prohibiting the Company from pursuing any other rights and remedies
available for any such breach or threatened breach. 

  

	 	(e)	Employee agrees that upon termination or separation of Employee’s employment with the Company for any reason, Employee shall immediately return to the Company all Confidential Information in Employee’s
possession in whatever form maintained (including, without limitation, computer disks and other electronic and digital media). 

  

	 	(f)	The obligations of the Employee under this Section 8 shall, except as otherwise provided herein, survive the termination of the Employment Term or the termination or separation of Employee’s employment with the
Company to the maximum period allowed by applicable law. 

  

	9.	Termination. 

  

	 	(a)	Employee’s employment hereunder shall be terminated upon the occurrence of any of the following: 

  

	 	(i)	death of the Employee (Death); 

  

	 	(ii)	Employee’s inability to perform her duties or the essential functions of her job, with or without accommodation, on account of disability or incapacity for a period of one hundred eighty (180) or more days, whether
or not consecutive, within any period of twelve (12) consecutive months (Disability); 

  

	 	(iii)	Company Termination for Cause (as defined herein); 

  

	 	(iv)	Company Termination Without Cause (as defined herein); 

  

	 	(v)	Employee Termination for Good Cause (as defined herein); or 

  

	 	(vi)	Employee Termination Without Good Cause (as defined herein). 

  
 6 

	 	(b)	As used in this Agreement, “Company Termination for Cause” shall mean a termination of Employee’s employment by action of the Board of Directors or the Chief Executive Officer (or their or his/her
designee) at any time, including during the Employment Term, based on any one or more of the following: 

  

	 	(i)	Employee’s conviction, guilty plea or plea of nolo contendere to any felony, or to any crime of moral turpitude; 

  

	 	(ii)	the willful misconduct of Employee, or the willful or continued failure by Employee (except as a result of Disability or illness) to substantially perform her duties to the Company, in either case which has a material
adverse effect on Company; or 

  

	 	(iii)	the willful fraud or material dishonesty of Employee in connection with her performance of duties to the Company; 

provided, however, that no Company Termination for Cause shall be deemed to have occurred unless Employee is first given the
opportunity to cure any acts or omissions giving rise to a Company Termination for Cause (other than those acts or omissions set forth in subsection 9(b)(i)) within 30 days of Employee’s receipt of notice of such acts or omissions. 

 

	 	(c)	For purposes of this Agreement, “Company Termination Without Cause” shall mean a termination of Employee’s employment by the Company or the Company’s nonrenewal of this Agreement for any reason or on
any grounds other than a “Company Termination for Cause.” 

  

	 	(d)	For purposes of this Agreement, “Employee Termination Without Good Cause” shall mean a termination or resignation of employment by Employee or Employee’s nonrenewal of this Agreement for any reason or for
any grounds other than an “Employee Termination for Good Cause.” 

  

	 	(e)	For purposes of this Agreement, “Employee Termination for Good Cause” shall mean Employee’s termination of or resignation from Employment or Employee’s nonrenewal of this Agreement for any one or
more of the following reasons: 

  

	 	(i)	a material diminution in Employee’s authority, duties or responsibilities; 

  

	 	(ii)	a material reduction in Employee’s Salary; 

  

	 	(iii)	a material reduction in the Employee’s ability to earn an annual Bonus that results in a material reduction in the total annual compensation Employee may earn; 

  
 7 

	 	(iv)	a termination of Employee’s participation in employee benefits provided or existing as of the Effective Date unless such termination of employee benefits is applicable to all senior executive officers of the
Company or unless termination is required or directed under the terms and conditions of any applicable benefit plans, summary plan descriptions, insurance policies or applicable law; 

 

	 	(v)	the relocation of Employee’s principal place of employment to a location more than 35 miles from Employee’s principal place of business; or 

 

	 	(vi)	a material breach by the Company of this Agreement or any other agreement governing Employee’s employment by the Company; 

provided, however, that Employee may not terminate or separate employment for purposes of Employee Termination for Good Cause
unless (i) within 60 days after the date on which Employee obtains actual knowledge of the condition or event giving rise to Employee Termination for Good Cause, Employee gives notice to the Company that Employee does not wish to remain in the
employ of the Company as a result of such condition or event, (ii) the Company does not cure such condition or event within 30 days after receiving the notice described in the preceding clause (i), and (iii) Employee terminates employment within 180
days after the date on which Employee obtains actual knowledge of the existence of such condition or event. Any failure by Employee to terminate employment within such 180 day period after the initial existence of any condition or event giving rise
to Employee Termination for Good Cause shall constitute a waiver by Employee of the Employee’s right to claim an Employee Termination for Good Cause as a result of such condition or event. 

 

	 	(f)	 In the event that Employee’s employment is terminated at any time by a Company Termination Without Cause or an Employee Termination for Good
Cause, for a twelve month period following the effective date of such termination, the Company shall pay monthly (as severance, termination pay, separation pay, contract payout, compensation, or liquidated damages) (i) the monthly Salary that
would have otherwise been payable to the Employee during such period, and (ii) an amount equal to one-twelfth of the average of the three Bonuses (other than any Bonuses granted to Employee under any plan or program that provides incentive
compensation based on a performance period of more than one year, including any Long-Term Incentive Award granted under the AMERISAFE, Inc. 2012 Equity and Incentive Compensation Plan or any successor plan) most recently awarded under 6(b) and under
predecessor agreements (or, if less than three, the average of all Bonuses awarded under 6(b) and under predecessor agreements). Each such monthly payment shall be treated as a separate payment for purposes of Section 409A of the Internal Revenue
Code of 1986, as amended (the “Code”), and will be paid during such period in accordance with the Company’s then existing payroll practices, methods, or pay periods. In addition, in the event that Employee’s employment is
terminated at any time by a Company Termination Without Cause or an Employee Termination for Good Cause, the 

  
 8 

	 	
Company will pay or reimburse Employee for a twelve month period following such termination the actual cost of COBRA continuing health coverage premiums, to the extent COBRA is applicable and
Employee elects COBRA continuing health coverage. In this regard, if Employee is eligible for COBRA continuing health benefits and if Employee timely elects COBRA continuing health care coverage, the Company will pay and/or reimburse up to a maximum
of twelve months of COBRA continuing health care coverage premiums provided that such COBRA premiums shall be reimbursed, if at all, not later than the year following that in which such premiums are incurred, and that the amount of premiums
eligible for reimbursement during one taxable year may not affect the amount of premiums eligible for reimbursement in another taxable year. It shall be at Company’s option and discretion to either pay the COBRA premiums directly or to
reimburse Employee for premiums that Employee pays for COBRA continuing health coverage. Any premiums or amounts due for COBRA continuing health coverage beyond the twelve month period referenced above shall be at the sole cost and expense of
Employee and will not be paid or reimbursed by the Company. The above described obligations of the Company (continuation of Salary and Bonus for a twelve month period following and payment of COBRA premiums for a twelve month period following
Company Termination Without Cause or Employee Termination for Good Cause) shall be the exclusive remedies and payment obligations and no other amounts or obligations will be due and owing by the Company to Employee. In this regard, Company
Termination Without Cause and Employee Termination for Good Cause may be effectuated at any time during the Employment Term or renewal and the only amounts that Company will be obligated or required to pay are the amounts calculated according to the
formulas set forth above. 

  

	 	(g)	Notwithstanding anything to the contrary expressed or implied herein, except as required by applicable law and except as set forth in Section 9(f) above, the Company shall not be obligated to make any payments to the
Employee or on her behalf of whatever kind or nature by reason of the Employee’s cessation of employment (including, without limitation, by reason of a Company Termination for Cause, Employee Termination Without Good Cause, Death or
Disability), other than (i) such amounts, if any, of Employee’s Salary and Bonus as shall be accrued, earned and remained unpaid as of the effective date of employment separation and (ii) such other amounts, if any, which may be then otherwise
payable to the Employee pursuant to the terms of the Company’s benefits plans or pursuant to Section 7 above. Any Bonus amounts due the Employee following a cessation of employment shall be paid following the end of the fiscal year at the same
time Bonus payments are made to other employees. 

  

	 	(h)	 To the extent that a payment becomes due to Employee under this Agreement by reason of Employee’s termination of employment, the term
“termination of employment” will have the same meaning as “separation from service” under Section 409A of the Code. Notwithstanding anything to the contrary expressed or implied herein, if the Company makes a good faith
determination that a payment under the Agreement (i) constitutes a deferral of compensation for purposes of 

  
 9 

	 	
Section 409A of the Code, (ii) is made to Employee by reason of her separation from service and (iii) at the time such payment would otherwise be made Employee is a “specified employee”
within the meaning of Section 409A of the Code, the payment will be delayed until the first day of the seventh month following the date of such termination of employment to the extent required by Section 409A of the Code. 

 

	10.	Restrictive Covenants: Non-Competition and Non-Solicitation. 

  

	 	(a)	Introduction. The restrictive covenants set forth in this Agreement prohibiting competition and solicitation shall apply during the “Restricted Period,” as defined herein, in the “Restricted
Area,” as defined herein. Employee acknowledges and understands that one of the principal causes and considerations of the Company employing or continuing to employ Employee in a senior executive officer position is the restrictive covenants to
which Employee is obligated under this Agreement. Employee further acknowledges and agrees that she will be granted access to and will be provided confidential, business and proprietary information and trade secrets of the Company and that she will
have access to and will be provided confidential information and data to which only senior executive officers have access and that the provision and access of such information constitutes additional consideration in exchange for the restrictive
covenants contained herein. Additionally, the Company will continue to be providing to Employee special and unique training opportunities and experience and she will be obtaining knowledge, experience and skills through employment with the Company
that may not otherwise be obtained or acquired by Employee. 

  

	 	(b)	Restricted Period. For purposes of this Agreement, the “Restricted Period” shall mean the Employment Term plus: 

  

	 	(i)	in the event that the employment of the Employee is terminated by a Company Termination Without Cause or Employee Termination For Good Cause, a period of twelve months. As such, the Restricted Period would be the
Employment Term and duration of employment and would extend beyond termination or separation for twelve months; or 

  

	 	(ii)	 in the event that the employment of the Employee is terminated by the Company by a Company Termination For Cause, or by Employee’s Termination
Without Good Cause, the Restricted Period shall expire upon the effective date of Employee’s separation of employment; provided, however, in such event, the Company shall have the exclusive option and absolute right of extending the Restrictive
Period for a period of twelve months following the effective date of the termination or separation of employment if Company: (1) delivers written notice to the Employee irrevocably exercising such option before employment termination or separation
or within 180 days after employment separation or termination and (2) agrees to pay and does pay the Employee the payments provided for under Section 9(f) of this Agreement for such twelve month period. If

  
 10 

	 	
Company exercises this option and right and complies with the requirements for same, the Restrictive Period shall be extended beyond the employment separation effective date for the twelve month
period designed and Employee agrees and acknowledges that Employee is bound by such restrictive covenants for the Restrictive Period.

  

	 	(c)	Definition of Restricted Area. The term “Restricted Area” shall mean the states, parishes, counties and municipalities designated in Attachment “A” which is incorporated herein by reference as
if copied in extension. 

  

	 	(d)	Business of the Company. Employee acknowledges and understands that the “business” of the Company involves and relates to the underwriting of risks for, the sale of and the servicing of workers’
compensation insurance, general liability insurance and commercial and business insurance product lines and related services. Employee further acknowledges, agrees and represents that she understands and knows the business in which the Company is
engaged and the scope, activities and business pursuits involved in the business of the Company. Employee further acknowledges and understands that the noncompetition and nonsolicitation of customer restrictions in this Agreement prohibit the
Employee from engaging, in any capacity or any position, and from conducting any activities or business similar to that of the Company or that is competitive with the Company and as provided under the specific terms and conditions of this Agreement.

  

	 	(e)	Customers of the Company. For purposes of this Agreement, “customers” shall include, but are not limited to, insured businesses, persons and entities who have or have had insurance coverage with the
Company and insurance agents with whom Company has contracts, agreements, arrangements or any type of business, insurance placement or working relationship. Employee acknowledges and represents that Employee understands the nature of the
Company’s customer relationships and who and what comprises its customers. 

  

	 	(f)	Non-Competition. During the Restricted Period, Employee shall not engage in any of the following activities in the Restricted Area: 

 

	 	(i)	Carry on or engage in her own business (as a sole proprietor, corporation, partnership, limited liability company, limited partnership or any other business entity or business association) in competition with or similar
to the business of the Company. 

  

	 	(ii)	Carry on or engage in a competing business or work similar to or in competition with the business of the Company as an employee, consultant, board member, officer, manager, representative, contractor, consultant,
subcontractor, independent contractor or agent of any other person or entity or in any capacity with or for any other person or entity. 

  
 11 

	 	(iii)	Acquire or have an interest in or an option or other right to acquire an interest in any entity or business which is carrying on or engaging in a competing business with the Company or in a business similar to that of
the Company. The term “an interest” shall include, without limitation, an interest or right as a partner, shareholder, officer, director, member, general manager, principal, limited partner, owner, trustee, financier, guarantor, surety,
mortgagee and lender. 

  

	 	(iv)	Accept or conduct any business or any transactions with any customer or former customer of the Company or receive any compensation, remuneration or consideration arising out of, related to or in any associated with any
business arrangement or relationship with any customer or former customer of the Company. 

  

	 	(g)	Non-Solicitation. During the Restricted Period, Employee shall not engage in the following activities in the Restricted Area: 

 

	 	(i)	Solicit the customers of the Company. 

  

	 	(ii)	Solicit the customers or former customers of Employee. 

  

	 	(iii)	Accept business from any customer of the Company. 

  

	 	(iv)	Accept business from any customer or former customer of Employee. 

  

	 	(v)	Service accounts or business of any customers of the Company. 

  

	 	(vi)	Service accounts or business of any customers or former customers of Employee. 

  

	 	(vii)	Solicit, induce or attempt to induce any employee of the Company to leave the employ of the Company. 

  

	 	(h)	Application. Company and Employee agree that (i) each of the actions described in this Agreement constitute “carrying on and engaging in a business similar to that of” Company and the “soliciting
customers of” Company, as those terms are used in La.R.S. 23:921, and (ii) this Agreement shall have the broadest possible meaning and application as allowed under applicable law. Additionally, any future amendment to La.R.S. 23:921 or
decisions or rulings of any court of competent jurisdiction which would expand the Company’s rights or impose greater restrictions on Employee shall apply and shall be enforceable herein. For purposes of this Agreement, the term
“solicit” includes, but is in no way limited to, any and all direct and indirect solicitation of business (by Employee or through others) and the engagement in communications (through any format or medium) for the purpose of or which would
in any way facilitate or attempt to generate business, services, work or other business activities with the customer and this shall apply regardless of whether the customer initiates the contact with Employee or Employee (or another person or
entity) initiates the contact with the customer. 

  
 12 

	 	(i)	Remedies. In the event of breach or threatened or attempted breach of any provision of this Agreement by Employee, the parties recognize and acknowledge that such a breach would cause irreparable harm to the
Company or that the Company may not have an adequate remedy at law and that the restrictive covenants contained in this Agreement are “obligations not to do” and that the Company shall not be required to prove irreparable injury in order
to obtain injunctive relief in the event of any breach or threatened breach of this Agreement. Employee further agree and acknowledge that if there is any breach or threatened breach of any one or more of the provisions of this Agreement, the
Company may, in addition to any other legal or equitable remedies which may be available to it, (i) obtain a temporary restraining order, preliminary injunction and permanent injunction to enjoin or restrain Employee from the breach or threatened
breach of any such provision or provisions without the necessity of posting a bond and (ii) require Employee to account for and pay over to the Company all compensation, profits, moneys, accruals, increments, remuneration or any other benefits
derived or received by Employee as a result of any transactions or actions constituting a breach of any provision of this Agreement. Company shall also be entitled to recover any damages, attorney’s fees and costs incurred by it in any legal
action or to obtain specific performance of or to enforce this Agreement or to remedy any breach of this Agreement. All such remedies in favor of the Company shall be cumulative and shall not be exclusive. In the event that the Company takes any
legal action to enforce this Agreement or to remedy any breach of this Agreement, the Company shall be entitled to recover and the Employee shall be liable for all attorney’s fees, court costs and expenses incurred by the Company in any such
action. 

  

	 	(j)	Company Designation. As used in this Section 10, “Company” includes Amerisafe, Inc., American Interstate Insurance Company, Silver Oak Casualty, Inc., American Interstate Insurance Company of Texas,
Amerisafe General Agency, Inc. and any and all predecessor entities, successor entities, affiliate entities, parent companies, assigns and subsidiaries. The parties acknowledge and agree that the restrictive covenants in this Section 10 enure to the
benefit of and operate for the interest of all of the above-mentioned companies and affiliates and said entities are expressly designated as third party beneficiaries of this Section 10 and the restrictive covenants and obligations imposed on
Employee. 

  

	 	(k)	 Construction Reformation and Severability. It is understood and agreed that, should any portion of any clause or paragraph of this Section 10
be deemed too broad to permit enforcement to its full extent, or should any portion of any clause or paragraph of this Section 10 be deemed unreasonable, invalid or unenforceable, then said clause or paragraph shall be reformed and enforced to the
maximum extent permitted by law. Additionally, if any of the provisions of this Section 10 are ever found by a court of competent jurisdiction to exceed the maximum enforceable (i) periods of time, (ii) geographic areas of restriction, (iii) scope
of noncompetition or nonsolicitation or (iv) description of the Company’s business or customers, or for any other reason, then such unenforceable element(s) of this Section 10 shall be reformed and reduced to the maximum periods of time,

  
 13 

	 	
geographic areas of restriction, scope of noncompetition or nonsolicitation or description of the Company’s business that is permitted by law. In this regard, any unenforceable, unreasonable
or overly broad provision shall be reformed or severed so as to permit enforcement to the fullest extent permitted by law and reformation and severability shall apply. 

 

	 	(l)	Reasonableness. Employee acknowledges, represents and agrees that the restrictive covenants in this Section 10 are reasonable in nature, scope, time and territory and in the terms and conditions set forth herein.
Employee acknowledges, represents and agrees that the Company has expended substantial cost in training Employee and that the Company has provided him with access to valuable information and has provided him with valuable experience. In addition,
Employee acknowledges, represents and agrees that the Company has placed Employee in contact with its customers, and has made Employee part of its business plans. Employee further acknowledges, represents and agrees that Employee would not have
obtained such training, experience, contacts and information from other sources without the employment relationship with the Company. Employee further acknowledges, represents and agrees that the foregoing have occurred or resulted based on the
Company’s reliance on these restrictive covenants and Employee’s representations and obligations made herein. Employee further acknowledges, represents and agrees that this Section 10 and the obligations of Employee under these restrictive
covenants are reasonable in order to protect the legitimate interests of the Company. Employee further acknowledges, represents and agrees that by virtue of her job position, she has become an integral and influential component of the Company’s
current and future business plans. It is the Employee’s desire and intent that this Agreement be given full force and effect. Employee further acknowledges and agrees that enforcement of these restrictive covenants will not create an undue
burden or hardship on him and will not impair or prevent him from earning a livelihood based on her own education, training, experience, qualifications, and skills. 

 

	11.	Assignment. 

  

	 	(a)	Neither this Agreement nor any right or interest hereunder shall be assignable by the Employee or her beneficiaries or legal representatives without the Company’s prior written consent; provided, however, that
nothing in this Section 11(a) shall preclude the Employee from designating a beneficiary to receive any benefit payable hereunder upon her death or incapacity. 

  

	 	(b)	Except as required by law, no right to receive payments under this Agreement shall be subject to anticipation, commutation, alienation, sale, assignment, encumbrance, charge, pledge, or hypothecation or to exclusion,
attachment, levy or similar process or to assignment by operation of law, and any attempt, voluntary or involuntary, to effect any such action shall be null, void and of no effect. 

  
 14 

	 	(c)	Company shall have the right, without Employee’s consent, to assign this Agreement and to assign any rights and obligations under this Agreement to any person or entity including, but in no way limited to, any
parent companies, subsidiaries, affiliate entities, predecessors, and successors. 

  

	12.	Binding Effect. Without limiting or diminishing the effect of Section 11 hereof, this Agreement shall inure to the benefit of and be binding upon the parties hereto and their respective heirs, successors, legal
representatives and assigns. 

  

	13.	Notices. All notices which are required or may be given pursuant to the terms of this Agreement shall be in writing and shall be sufficient in all respects if given in writing and (i) delivered personally, (ii)
five business days after being mailed by certified or registered mail, return receipt requested and postage prepaid, (iii) sent via a nationally recognized overnight courier, or (iv) sent via facsimile confirmed by certified or registered mail,
return receipt requested and postage prepaid, if to the Company at the Company’s principal place of business, and if to the Employee, at her home address most recently filed with the Company, or to such other address or addresses as either
party shall have designated in writing to the other party hereto. 

  

	14.	Law Governing. This Agreement shall be governed by and construed in accordance with the laws of the State of Louisiana, without regard to the application of conflicts of laws principles. Employee consents to the
jurisdiction and venue of the 36th Judicial District Court, Beauregard Parish, State of Louisiana and, alternatively, the U.S. District Court for the Western District of Louisiana, Lake Charles Division. 

 

	15.	Execution and Performance. Employee agrees and understands that this Agreement is being executed, in whole or in part, in Beauregard Parish, Louisiana. Additionally, performance of this Agreement is to be
rendered, in whole or in part, in Beauregard Parish, Louisiana. Employee further understands and acknowledges that the employment relationship between Employee and the Company is principally centered and based in Beauregard Parish, Louisiana.

  

	16.	Severability. The Employee agrees that in the event that any court of competent jurisdiction shall finally hold that any provision of this Agreement is void or constitutes an unreasonable restriction against the
Employee, this Agreement shall not be rendered void but shall apply with respect to such extent as such court may judicially determine constitutes a reasonable restriction under the circumstances. If any part of this Agreement is held by a court of
competent jurisdiction to be invalid, illegible or incapable of being enforced in whole or in part by reason of any rule of law or public policy, such part shall be deemed to be severed from the remainder of this Agreement for the purpose only of
the particular legal proceedings in question and all other covenants and provisions of this Agreement shall in every other respect continue in full force and effect and no covenant or provision shall be deemed dependent upon any other covenant or
provision. Severability and reformation shall apply. 

  
 15 

 It is understood and agreed that should any portion of any clause or paragraph of this Agreement
be deemed too broad to permit enforcement to its full extent or should any portion of any clause or paragraph of this Agreement be deemed unreasonable, then said clause or paragraph shall be reformed and enforced to the maximum extent permitted by
law. 
  

	17.	Waiver. Failure to insist upon strict compliance with any of the terms, covenants or conditions hereof shall not be deemed a waiver of such term, covenant or condition, nor shall any waiver or relinquishment of
any right or power hereunder at any one or more times be deemed a waiver or relinquishment of such right or power at any other time or times. 

  

	18.	Entire Agreement; Modifications. This Agreement, with referenced Attachment “A”, constitutes the entire and final expression of the agreement of the parties with respect to the subject matter hereof and
supersedes the Prior Agreement and other prior and contemporaneous agreements, oral and written, between the parties hereto with respect to the subject matter hereof. This Agreement may be modified or amended only by an instrument in writing signed
by both Employee and the Chairman of the Committee , provided, however, that in light of the uncertainty with respect to the proper application of Section 409A of the Code, the Company reserves the right to make amendments to the Agreement as the
Company deems necessary or desirable solely to avoid the imposition of taxes or penalties under Section 409A. 

  

	19.	Counterparts and Multiple Originals. This Agreement may be executed in two or more counterparts and in multiple originals, each of which shall be deemed an original, but all of which together shall constitute one
and the same instrument. 

  

	20.	Interpretation. The Company and Employee have jointly participated in the negotiations and drafting of this Agreement. In the event any question of intent or interpretation arises, this Agreement shall be
construed and interpreted as if drafted by both parties. 

  

	21.	References to Attachments. All attachments and other documents which are referred to herein are hereby incorporated by reference as if copied at length herein. 

 

	22.	Consultation and Acknowledgment. Employee acknowledges and agrees that Employee has read and understands this Agreement and its effect, and that Employee has had the opportunity to consult fully and freely with
an attorney or other advisor of her choice regarding this Agreement and to have an attorney or advisor review and advise Employee with respect to this Agreement prior to her entering into this Agreement. Employee further acknowledges that she has
carefully read this entire Agreement and understands the nature and extent of the rights and obligations created by this Agreement and that she is entering into this Agreement voluntarily and without coercion. Employee further acknowledges that this
Agreement is being entered into after due thought and consideration and after a mutual and meaningful negotiation between the parties. 

[signature page follows] 

  
 16 

 IN WITNESS WHEREOF, the parties have executed and delivered this Agreement as of the date first
written above. 
  

			
	AMERISAFE, INC.
		
	 By:
	 	 /s/ G. Janelle Frost

		 	G. Janelle Frost,
		 	Chief Executive Officer
	
	EMPLOYEE:
	
	 /s/ Kathryn H. Shirley

	Kathryn H. Shirley

  
 17 

 ATTACHMENT “A” 

Employment Agreement 
 “Restricted
Area” 
 The following states constitute the “Restricted Area” for purposes of the Employment Agreement, including Section 10, entitled
“Restrictive Covenants”, entered into between the Company and the Employee: 
 States of Alabama, Alaska, Arkansas, California, Colorado,
Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, North
Carolina, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, Wisconsin and Wyoming. 

  
 18

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