Document:

Exhibit 10(kkk)

                             FIFTH AMENDMENT TO THE
                              NORTH VALLEY BANCORP
                          EMPLOYEE STOCK OWNERSHIP PLAN
                          -----------------------------

This Fifth Amendment (Amendment) is hereby adopted by North Valley Bancorp
(Employer).

                                    RECITALS
                                    --------

A.   The Employer adopted The North Valley Bancorp Employee Stock Ownership Plan
     (ESOP), effective January 1, 1977.

B.   The ESOP was amended from time to time and was restated effective January
     1, 1999.

C.   The ESOP received a favorable determination letter as to the tax qualified
     status of the ESOP, dated March 29, 2000.

D.   Effective October 11, 2000, the Six Rivers National Bank Employee Stock
     Ownership Plan was merged into the ESOP.

E.   The Employer amended the ESOP to:

     1.  Reflect the provisions of the Community Renewal Tax Relief Act of 2000
         (CRA 2000) by adding the model amendment language suggested by the
         Internal Revenue Service (IRS) in IRS Notice 2001-37, dealing with the
         definition of compensation for certain plan purposes;

     2.  Conform to the final regulations under the Internal Revenue Code (Code)
         section 401(a)(9) published on April 17, 2002, relating to required
         minimum distributions from retirement plans;

     3.  Reflect certain provisions of the Economic Growth and Tax Relief
         Reconciliation Act of 2001 (EGTRRA). The amendments reflect the model
         amendment language suggested by the IRS in Notice 2001-57, dealing with
         certain plan limits and other general matters;

     4.  Amend the Claims Procedure article of the ESOP to reflect the final
         regulations issued by the Department of Labor (DOL), effective for all
         claims filed on or after January 1, 2002; and

     5.  Clarify the definition of Disability under the ESOP.

                                      -1-
<PAGE>

F.   The Employer amended the ESOP to clarify certain provisions relating to the
     definition of the allocation date, investment accounts, Bancorp stock
     dividends, vesting and distributions from the Trust.

G.   The Employer amended the ESOP, in light of the merger of Yolo Community
     Bank (YCB) and North Valley Bancorp, effective on or about August 31, 2004,
     to provide for the immediate participation of YCB employees, effective
     September 1, 2004, and the crediting of service with YCB for eligibility
     and vesting purposes under the ESOP.

H.   The Employer amended the ESOP, in accordance with Code section
     401(a)(31)(B) regarding mandatory distributions, to reduce the limit for
     making distributions without participant consent from five thousand dollars
     ($5,000) to one thousand dollars ($1,000), effective March 28, 2005.

I.   The Employer now wishes to amend the ESOP to provide for the crediting of
     all years of service with YCB for vesting purposes under the ESOP, not just
     years of service credited under YCB beginning with the effective date of
     the Yolo Community Bank Employee Stock Ownership Plan, so as to comply with
     the terms of the merger agreement between YCB and North Valley Bancorp.

                              OPERATIVE PROVISIONS
                              --------------------

In accordance with the foregoing recitals, the Employer hereby amends the ESOP
effective September 1, 2004, or as of such other specified dates, as follows:

1.   Section 11(a), pertaining to Credited Service, is amended by deleting the
     last two sentences that were added to the end of that subsection by the
     Third Amendment and the addition of the following sentences to the end of
     that subsection, which reads as follows:

                  For Employees who were employed by Yolo Community Bank on
                  September 1, 2004, Credited Service shall also include the
                  total number of calendar years in which the Participant was
                  credited with at least one thousand (1,000) Hours of Service
                  with Yolo Community Bank if such Participant became an
                  Employee of the Employer by reason of the merger of Yolo
                  Community Bank into a wholly-owned subsidiary of Bancorp on or
                  around August 31, 2004 (Merger). Service with Yolo Community
                  Bank, before the Merger and service with the wholly owned
                  subsidiary of Bancorp after the merger, will be counted for
                  purposes of determining Credited Service.

                                      -2-
<PAGE>

2.   In all other respects, the ESOP is hereby ratified, approved and confirmed.

IN WITNESS WHEREOF, the Employer has executed and adopted this Amendment on this
4th day of June, 2005.

                                       EMPLOYER:
                                       ---------

                                       NORTH VALLEY BANCORP
                                       A California Corporation

                                       By: /s/ MICHAEL J. CUSHMAN
                                           -------------------------------------
                                           Michael J. Cushman, President

                                      -3-Exhibit 10.20

Participants in Officer Group Term Replacement Plan

	
  
Steven Bacon
  
	
  
Paul Banfield
  
	
  
Robert Bantle*
  
	
  
Terry Barber
  
	
  
Francis Benedict
  
	
  
David Boyce*
  
	
  
Samuel Brewer
  
	
  
John Butler
  
	
  
James Byrnes*
  
	
  
Edward Dawson
  
	
  
Jeffrey Dobbin
  
	
  
Richard Dolge
  
	
  
Richard Farr
  
	
  
Francis Fetsko*
  
	
  
James Fulmer*
  
	
  Stephen Garner*
  
	
  
Benjamin Herrmann
  
	
  
Stephen Hoyt
  
	
  
Diana Jayne
  
	
  
Joyce Maglione
  
	
  
H. Craig Miller
  
	
  
Stephen Patchett
  
	
  
Joseph Perry
  
	
  
Stephen Romaine*
  
	
  
Thomas Smith
  
	
  
Donald Stewart*
  
	
  
Lawrence Updike*
  
	
  
Pamela Wait
  
	
   
 
	
  

  
	
  
* Exhibit D to Officer Group Term Replacement Plan   for each of these executive officers filed individually.
  

 

  

TOMPKINS TRUSTCO, INC.

OFFICER GROUP TERM REPLACEMENT PLAN

          THIS PLAN, hereby made and entered into this         day of_____________, 2005, by and between Tompkins Trustco, Inc., a financial services holding company including as affiliates Tompkins Trust Company, Mahopac National Bank, The Bank of Castile and Tompkins Insurance Agencies, Inc. (the “Company”) and the Participant selected to participate in this Plan (the “Participant”).

INTRODUCTION

     The Company wishes to attract and retain highly qualified executives.  To further this objective, the Company is willing to divide the death proceeds of certain life insurance policies which are owned by the Company on the lives of the participating executives with the designated beneficiary of each insured participant executive.  The Company will pay life insurance premiums from its general assets.

Article 1

General Definitions

The following terms shall have the meanings specified:

          1.1     “Change of Control” means any of the following:

	
  
 
  	
  
          1.1.1               a
reorganization, merger, consolidation or sale of substantially all of the assets
of the Company, or a similar transaction in which the Company is not the
resulting entity; or
 
	
   
  	
  
 
  
	
  
 
  	
  
          1.1.2          individuals   who constitute the Incumbent Board (as herein defined) of the Company cease   for any reason to constitute a majority thereof.  For these purposes, “Incumbent Board” means the members of the   Board of Directors of the Company on the effective date of the Plan, provided   that any person becoming a member of the Board of Directors subsequent to   such effective date, whose election was approved by a vote of at least   three-quarters of the members of the Board of Directors comprising the   Incumbent Board, or whose nomination for election by members or stockholders   was approved by the same nominating committee serving under an Incumbent   Board, shall be considered as though he were a member of the Incumbent
Board.
  

 

  

          1.2     “Compensation Committee” means either the Compensation Committee designated from time to time by the Company’s Board of Directors or a majority of the Company’s Board of Directors, either of which shall hereinafter be referred to as the Compensation Committee.

          1.3     “Disability” means the Participant’s inability to perform substantially all normal duties of an employee, as determined by the Company’s Board of Directors in its sole discretion.  As a condition to any benefits, the Company may require the Participant to submit to such physical or mental evaluations and tests as the Board of Directors deems appropriate.

          1.4     “Insured” means the individual whose life is insured.

          1.5     “Insurer” means the insurance company issuing the life insurance policy on the life of the insured.

          1.6     “Other Group Term Coverage” means group term life insurance maintained on a Participant’s life owned by the Company that is in addition to the Policies covered under this Plan.

          1.7     “Normal Retirement Age” means age 65.

          1.8     “Normal Retirement Date” means the later of the Normal Retirement Age or the date that the Participant terminates or is terminated for any reason other than being Terminated for Cause.

          1.9     “Participant” means the executive who is eligible to participate in the Plan as determined by the Compensation Committee, elects in writing to participate in the Plan using the form attached hereto as Exhibit A, and signs a Split Dollar Endorsement for the Policy in which he or she is the Insured.

          1.10   “Policy” or “Policies” means the individual insurance policy (or policies) adopted by the Compensation Committee for purposes of insuring a Participant’s life under this Plan.

          1.11   “Base Annual Salary” means the current base annual salary at the earliest of (1) the date of the participant’s death; (2) the date of the participant’s disability; (3) the participant’s retirement age, or the date of change of control.

          1.12   “Plan” means this instrument, including all amendments thereto.

          1.13   “Terminated for Cause” means that the Company has terminated the Participant’s employment for any of the following reasons:

 

  

	
  
 
  	
  
          1.13.1     Gross   negligence or gross neglect of duties;
  
	
  
 
  	
  
 
  
	
  
 
  	
  
          1.13.2     Commission   of a felony or of a gross misdemeanor involving moral turpitude;
  

     1.12.3       Fraud, disloyalty, dishonesty or willful violation of any law or significant Company policy committed in connection with the Participant’s employment and resulting in an adverse effect on the Company.

Article 2

Participation

          2.1       Eligibility to Participate.  The Compensation Committee in its sole discretion shall designate from time to time Participants that are eligible to participate in this Plan. 

          2.2         Participation.  The eligible executive may participate in this Plan by executing an Election to Participate (Exhibit A) and a Split Dollar Endorsement (Exhibit D).  The Split Dollar Endorsement shall bind the Participant and his or her beneficiaries, assigns and transferees, to the terms and conditions of this Plan.   An executive’s participation is limited to only Policies where he or she is the Insured.   Exhibit B attached hereto sets forth the a listing of Participants.  It is
intended that the Participant shall continue as a Participant until death. 

          2.3         Termination of Participation.  A Participant’s rights under this Plan shall cease and his or her participation in this Plan shall terminate if either or both of the following events occur:

	
  
 
  	
  
          2.3.1     The   Participant’s employment with the Company is Terminated for Cause;
  
	
  
 
  	
  
or
  
	
  
 
  	
  
          2.3.2     The   Participant’s employment with the Company is terminated prior to Normal   Retirement Age for reasons other than Disability.
  

          In the event the Company decides to maintain the Policy after the Participant’s termination of his or her participation in the Plan, the Company shall be the direct beneficiary of the entire proceeds of the Policy.

          2.4     Disability.  (A) Except as otherwise provided in paragraph (B) of this section 2.4, if the Participant’s employment with the Company is terminated because of the Participant’s Disability, the Company shall maintain the Policy in full force and effect and, in no event, shall the Company amend, terminate or otherwise abrogate the Participant’s interest in the Policy, provided, however, that at all times the Policy shall be subject to the claims of the Company’s creditors.

 

  

                    (B) Notwithstanding the provisions of paragraph (A) of this section 2.4, upon the Disabled Participant’s gainful employment with an entity other than the Company, the Company shall have not further obligation to the Disabled Participant, and the Disabled Participant’s rights pursuant to the Plan shall cease.  In the event the Disabled Participant’s rights are terminated hereunder, the Company shall be the direct beneficiary of the entire death proceeds of the Policy upon the death of the Disabled Participant.

          2.5          Retirement.  Upon the retirement of the Participant, the Company shall maintain the Policy in full force and effect and in no event shall the Company amend, terminate or otherwise abrogate the Participant’s interest in the Policy, provided, however that at all times the Policy shall be subject to the claims of the Company’s creditors.  The Participant’s interest in the Policy shall be subject to the vesting schedule attached hereto as Exhibit C.

Article 3

Policy Ownership/Interests

          3.1     Company Ownership.  The Company shall own Policies on each Participant’s life and shall have the right to exercise all incidents of ownership. The Policies, however, will be held in a Delaware Trust established and controlled by the Company.  With respect to each Policy, the Company shall be the direct beneficiary of an amount of death proceeds in excess of four times Base annual Salary prior to retirement, or the Multiple of the Base annual Salary of the insured/Participant based upon the Vesting Schedule attached hereto as Exhibit C following retirement.

          3.2     Participant’s Interest.  With respect to each Policy, the Participant, or the Participant’s assignee, shall have the right to designate the beneficiary of an amount of death benefit based upon the Plan formula as described in the Participant’s individual Split Dollar Endorsement.  The Participant shall also have the right to elect and change settlement options with the consent of the Company and the Insurer.

Article 4

Premiums

          4.1     Premium Payment.  The Company shall pay all premiums due on all Policies. 

          4.2     Imputed Income.  The Company shall impute income to the Participant in an amount equal to the current term rate for the Participant’s age multiplied by the aggregate death benefit payable to the Participant’s beneficiary.  The “current term rate” is the minimum amount required to be imputed under Revenue Rulings 64-328 and 66-110, or any subsequent applicable authority.   

 

  

Article 5

Assignment

     Any Participant may assign without consideration all interests in his or her Policy and in this Plan to any person, entity or trust.  In the event a Participant shall transfer all of his/her interest in the Policy, then all of that Participant’s interest in his or her Policy and in the Plan shall be vested in his/her transferee, who shall be substituted as a party hereunder, and that Participant shall have no further interest in his or her Policy or in this Plan.

Article 6

Insurer

     The Insurer shall be bound only by the terms of their corresponding Policy.  Any payments the Insurer makes or actions it takes in accordance with a Policy shall fully discharge it from all claims, suits and demands of all persons relating to that Policy.  The Insurer shall not be bound by the provisions of this Plan.  The Insurer shall have the right to rely on the Company’s representations with regard to any definitions, interpretations, or Policy interests as specified under this Plan.

Article 7

Claims Procedure

          7.1     Claims Procedure.  The Company shall notify any person or entity that makes a claim against this Group Term Replacement Plan (the “Claimant”) in writing, within ninety (90) days of Claimant’s written application for benefits, of Claimant’s eligibility or ineligibility for benefits under this Plan.  If the Company determines that Claimant is not eligible for benefits or full benefits, the notice shall set forth (1) the specific reasons for such denial, (2) a specific reference to the provisions of this Plan on which the denial is based, (3) a description of any additional information or material necessary for the Claimant to perfect Claimant’s claim, and a description of why it is needed, and (4) an explanation of this Plan’s claims review procedure and other appropriate information as to the steps to be taken if the Claimant
wishes to have the claim reviewed.  If the Company determines that there are special circumstances requiring additional time to make a decision, the Company shall notify the Claimant of the special circumstances and the date by which a decision is expected to be made, and may extend the time for up to an additional ninety-day period.  

 

  

          7.2     Review Procedure.  If a Claimant is determined by the Company not to be eligible for benefits, or if the Claimant believes that Claimant is entitled to greater or different benefits, the Claimant shall have the opportunity to have such claim reviewed by the Company by filing a petition for review with the Company within sixty (60) days after receipt of the notice issued by the Company.  Said petition shall state the specific reasons which the Claimant believes entitle Claimant to benefits or to greater or different benefits.  Within sixty (60) days after receipt by the Company of the petition, the Company shall afford the Claimant (and counsel, if any) an opportunity to present Claimant’s position to the Company orally or in writing, and the Claimant (or counsel) shall have the right to review the pertinent documents.  The Compan

notify the Claimant of its decision in writing within the sixty-day period, stating specifically the basis of its decision, written in a manner calculated to be understood by the Claimant and the specific provisions of this Plan on which the decision is based.  If, because of the need for a hearing, the sixty-day period is not sufficient, the decision may be deferred for up to another sixty-day period at the election of the Company, but notice of this deferral shall be given to the Claimant.

Article 8

Amendments and Termination

          8.1     Amendment or Termination of Plan.  Except as otherwise provided in sections 2.3, 2.4, 2.5 and 8.2, (i) the Company may amend or terminate the Plan at any time, and (ii) the Company may amend or terminate a Participant’s rights under the Plan at any time prior to a Participant’s death by written notice to the Participant.

          8.2     Amendment or Termination of Plan Upon Change of Control.  Notwithstanding the provisions of section 8.1, in the event of a Change of Control, the Company or its successor shall maintain in full force and effect each Policy that is in existence on the date the Change of Control occurs and not terminate or otherwise abrogate a Participant’s interest in the Policy, provided, however, that at all times the Policy shall be subject to the claims of the Company’s creditors.  This section 8.2 shall apply to all Participants in the Plan on the date the Change of Control occurs, including by not limited to (i) a retired Participant who has an interest in the Policy pursuant to section 2.5; (ii) a Disabled Participant who has an interest in the Policy pursuant to section 2.4; and (iii) a Participant whose employment is terminated as a result of a Change of
Control.

          8.3     Upon Change of Control, all Participants are 100% vested in the maximum benefit in the Participant’s Split Dollar Endorsement (Exhibit D), at the date of the Change of Control (the greater of 1(i) or 1(ii)).

          8.4     A Participant may, in the Participant’s sole and absolute discretion, waive his or her rights under the Plan at any time.  Any waiver permitted under this section 8.3 shall be in writing and delivered to the Board of Directors of the Company.

 

  

Article 9

Miscellaneous

          9.1     Binding Effect.  This Plan in conjunction with each Split Dollar Endorsement shall bind each Participant and the Company, their beneficiaries, survivors, executors, administrators and transferees, and any Policy beneficiary.

          9.2     No Guarantee of Employment.  This Plan is not an employment policy or contract.  It does not give a Participant the right to remain an employee of the Company, nor does it interfere with the Company’s right to discharge a Participant.  It also does not require a Participant to remain an employee nor interfere with a Participant’s right to terminate employment at any time.

          9.3     Applicable Law.  The Plan and all rights hereunder shall be governed by and construed according to the laws of New York, except to the extent preempted by the laws of the United States of America; provided, however, that with respect to the Policies owned by the Company or any insurable interest issues, the laws of Delaware shall govern.

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

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

          9.6     Administration.  The Company shall have powers which are necessary to administer this Plan, including but not limited to:

	
  
 
  	
  
          9.6.1     Interpreting   the provisions of the Plan;
  
	
  
 
  	
  
 
  
	
  
 
  	
  
          9.6.2     Establishing   and revising the method of accounting for the Plan;
  
	
   
  	
  
 
  
	
  
 
  	
  
          9.6.3     Maintaining   a record of benefit payments; and
  
	
  
 
  	
  
 
  
	
  
 
  	
  
          9.6.4     Establishing   rules and prescribing any forms necessary or desirable to administer the   Plan.
  

 

  

          9.7     Named Fiduciary.  For purposes of the Employee Retirement Income Security Act of 1974, if applicable, the Company shall be the named fiduciary and plan administrator under the Plan.  The named fiduciary may delegate to others certain aspects of the management and operation responsibilities of the plan including the employment of advisors and the delegation of ministerial duties to qualified individuals.

          IN WITNESS WHEREOF, the Company executes this Plan as of the date indicated above.

	
  
 
  	
  
COMPANY:
  
	
   
  	
  
 
  	
  
 
  
	
  
 
  	
  
Tompkins Trustco, Inc.
  
	
  
 
  	
  
 
  	
  
 
  
	
  
 
  	
  
By
  	
  
 
  
	
  
 
  	
  
 
  	
  

  
	
  
 
  	
  
Title
  	
  
 
  
	
  
 
  	
  
 
  	
  

  

 

  

EXHIBIT A

ELECTION TO PARTICIPATE

          I, _____________________________________________, an eligible Participant of the Tompkins Trustco, Inc. Group Term Replacement Plan (the “Plan”) dated ___________________, 2005, hereby elect to become a Participant of the Plan in accordance with Section 2.2 of the Plan.  Additionally, I acknowledge that I have read the Plan document and agree to be bound by its terms. 

          Executed this _____________ day of ____________________, 20___.

	
  
 
  	
  
 
  	
  
 
  
	
  

  	
  
 
  	
  

  
	
  
Witness
  	
  
 
  	
  
Participant
  

 

  

EXHIBIT B

LIST OF PARTICIPANTS

	
  Steven Bacon
  
	
  
Paul Banfield
  
	
  
Robert Bantle
  
	
  
Terry Barber
  
	
  
Francis Benedict
  
	
  
David Boyce
  
	
  
Samuel Brewer
  
	
  
John Butler
  
	
  
James Byrnes
  
	
  
Edward Dawson
  
	
  
Jeffrey Dobbin
  
	
  
Richard Dolge
  
	
  
Richard Farr
  
	
  
Frank Fetsko
  
	
  
James Fulmer
  
	
  
Stephen Garner
  
	
  
Benjamin Herrmann
  
	
  
Stephen Hoyt
  
	
  Diana Jayne
  
	
  
Joyce Maglione
  
	
  
H. Craig Miller
  
	
  
Stephen Patchett
  
	
  
Joseph Perry
  
	
  
Stephen Romaine
  
	
  
Thomas Smith
  
	
  
Donald Stewart
  
	
  
Lawrence Updike
  
	
  
Pamela Wait
  

 

  

EXHIBIT C

VESTING SCHEDULE

	
  
Retirement Age
  	
   
 	
  
Multiple of Base Annual Salary
  
	
  

  	
   
 	
  

  
	
  55-58
  	
   
 	
  
1
  
	
  
59
  	
   
 	
  
1.6
  
	
  
60
  	
   
 	
  
2.4
  
	
  
61
  	
   
 	
  
3.2
  
	
  
62 and above
  	
   
 	
  
4
  

 

  

EXHIBIT D

SPLIT DOLLAR POLICY ENDORSEMENT

	
  
Northwestern Mutual
  	
  
Insured: __________________                                        
  

Supplementing and amending the application of TOMPKINS TRUSTCO, INC. on to Northwestern Mutual, (“Insurer”), the applicant requests and directs that:

BENEFICIARIES

     1.  The beneficiary designated by the Insured, or his/her transferee shall be the beneficiary of the lesser of:  (i) four (4) times the Participant’s Base Annual Salary, less all sums as are payable by reason of any Group Term Insurance coverage on the life of the Participant; or (ii) $____________.

     2.  The beneficiary designated by the Insured, who has retired, shall be the beneficiary of the lesser of (i) an amount of death benefit proceeds based upon the Vesting Schedule attached hereto as Exhibit C, less all sums payable by reason of any group term insurance coverage on the life of the Participant; or (ii) $___________

     3.  The beneficiary of any remaining death proceeds shall be Tompkins Trustco, Inc., a financial services holding company (the “Company”).

OWNERSHIP

          4.  The Owner of the policy shall be the Company.  The Owner shall have all ownership rights in the Policy except as may be specifically granted to the Insured or his/her transferee in paragraph (4) of this endorsement.

          5.  The Insured or his/her transferee shall have the right to assign all rights and interests in the policy with respect to that portion of the death proceeds designated in paragraph (1) of this endorsement, and to exercise all settlement options with respect to such death proceeds.

 

  

MODIFICATION OF ASSIGNMENT PROVISIONS OF THE POLICY

Upon the death of the Insured, the interest of any collateral assignee of the Owner of the policy designated in (4) above shall be limited to the portion of the proceeds described in (3) above.

OWNERS AUTHORITY

The Insurer is hereby authorized to recognize the Owner’s claim to rights hereunder without investigating the reason for any action taken by the Owner, including its statement of the amount of premiums it has paid on the policy.  The signature of the Owner shall be sufficient for the exercise of any rights under this Endorsement and the receipt of the Owner for any sums received by it shall be a full discharge and release to the Insurer.  Any transferee’s rights shall be subject to this Endorsement.

Signed at __________________,New York, this _____ day of _________________, 20__.

COMPANY

	
  
 
  	
  
Tompkins Trustco, Inc.
  
	
  
 
  	
  
 
  
	
  
 
  	
  
By
  	
  
 
  
	
  
 
  	
  
 
  	
  

  
	
   
  	
  
Title
  	
  
 
  
	
  
 
  	
  
 
  	
  

  

 

  

Acceptance and Beneficiary Designation

The Insured accepts and agrees to the foregoing and, subject to the rights of the Owner as stated above, designates

	
  
 
  	
  
 
  	
  
 
  	
  
 
  	
  
as primary beneficiary, and
  
	
  

  	
  
 
  	
  

  	
  
 
  	
  
 
  
	
  (Name)
  	
  
 
  	
  
(Relationship)
  	
  
 
  	
  
 
  
	
  
 
  	
  
 
  	
  
 
  	
  
 
  	
  
 
  
	
  
 
  	
  
 
  	
  
 
  	
  
 
  	
  
as secondary beneficiary,
  
	
  

  	
  
 
  	
  

  	
  
 
  	
  
 
  
	
  
(Name)
  	
  
 
  	
  
(Relationship)
  	
  
 
  	
  
 
  
	
  of the portion of the proceeds described in (2)   above.
  	
   
  	
   
  

Signed at __________________, New York, this ______ day of ________________, 20__.

INSURED

	
   
  	
   
  
	
  

  	
   
  
	
   
  	
   
  
	
   
  	
   
  
	
  

  	
   
  
	
  (print name)

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