Document:

EXHIBIT 10.1

 

Exhibit 10.1

EXECUTION COPY

Option Grant Agreement 

     This Option Grant Agreement (the “Agreement”) is entered into this 29th day of June, 2005, by
and between, American Real Estate Partners, L.P., a Delaware master limited partnership (together,
with its successors, the “Partnership”), and Keith A. Meister (the “Optionee”), effective as of
June 29, 2005 (the “Grant Date”).

     In consideration of the premises, mutual covenants and agreements herein, the Partnership and
the Optionee agree as follows:

     1. Grant of Option. The Partnership hereby grants to the Optionee an option to purchase from
the Partnership, at a price of $35.00 per unit (the “Exercise Price”), up to 700,000 depositary
(common) units of the type of units currently listed on the New York Stock Exchange representing
limited partnership interests of the Partnership (the “Units”), subject to the provisions of this
Agreement (each an “Option,” collectively the “Options”).

     2. Vesting.

          (a) In General. All of the Options are nonvested and forfeitable as of the Grant Date.
Subject to the Optionee’s continued employment with the Partnership or American Property Investors,
Inc. (together, with its successors, the “General Partner”), Options with respect to 100,000 Units
will vest on each of the first seven anniversaries of the Grant Date.

          (b) Acceleration of Vesting. Notwithstanding Section (a), all Options that have not been
previously forfeited or expired shall become fully vested and nonforfeitable upon the earliest to
occur of the following: (I) the occurrence of a Change in Control (as defined in Appendix A),
vesting to occur immediately before such Change in Control, or (II) termination by the General
Partner or the Partnership of the Optionee’s employment with the Partnership or General Partner
without Cause.

     For purposes of this Agreement, Cause shall mean: (i) willful failure to carry out the
instructions of the Board of Directors of the General Partner or the Partnership (other than any
such failure resulting from incapacity due to a physical or mental illness or disability) which
failure continues for more than 48 hours after a written demand for performance is delivered to
Optionee by the General Partner or Partnership; (ii) substance abuse which materially affects
Optionee’s ability to discharge his duties; (iii) conviction of a crime (other than traffic
violations or similarly minor infractions of law) or being charged with a felony; (iv) federal or
state criminal indictment for securities law violation; (v) commission of a fraudulent act that
affects the Partnership, General Partner or any of their respective subsidiaries; (vi) breach of
any of the terms of an applicable written employment agreement between the Optionee and the General
Partner or the Partnership resulting in the termination of such agreement or the Optionee’s
employment thereunder for “Cause” as defined in such agreement; (vii) willful disclosure, not
required by any law or court order, of any material inside information of the Partnership, General
Partner or any of their respective subsidiaries, to persons not authorized to know the same; or
(viii) any act by the Optionee not authorized by the Partnership or the General Partner which
causes any gaming authorities, having jurisdiction over the Partnership or any of its affiliates,
to seek any redress or remedy against Optionee, the Partnership or its affiliates.

 

 

          (c) Cessation of Employment or Other Service Relationship. Except as provided in Section
2(b)(II), all unvested Options terminate immediately upon the cessation of the Optionee’s
employment with the Partnership or the General Partner.

          (d) Other Activities. The Parties acknowledge that the Optionee provides services to other
entities affiliated with Mr. Icahn and such performance of services does not violate the terms of
this Agreement or constitute Cause.

     3. Term of Options. The Options to purchase the 100,000 Units that vest on each of the first
six anniversaries of the Grant Date will expire at 5:00 p.m. Eastern Time on the last business day
preceding the seventh anniversary of the Grant Date and the Options to purchase the 100,000 Units
that vest on the seventh anniversary of the Grant Date will expire at 5:00 p.m. Eastern Time on the
last business day preceding the eighth anniversary of the Grant Date (each such business day prior
to an anniversary of the Grant Date, an “Expiration Date”).

     4. Exercise of Vested Options.

          (a) Right to Exercise. The Optionee may exercise a vested Option at any time on or before the
relevant Expiration Date, provided he is then in the employment of the Partnership or the General
Partner.

          (b) Exercise Period Following Termination of Employment or Other Service Relationship. Upon
cessation of the Optionee’s employment with the Partnership or General Partner the vested Options
shall terminate upon the earlier of (1) the 180th day following such cessation or (2)
the relevant Expiration Date.

          (c) Exercise Procedure. In order to exercise the Options, the following items must be
delivered to the Secretary of the General Partner (i) an exercise notice in the form attached
hereto as Appendix B, (ii) full payment of the Exercise Price for such Units, and (iii) an executed
copy of any other agreements or documents reasonably required by the General Partner or the
Partnership. An exercise will not be effective until all of the foregoing items are received by
Secretary of the General Partner.

          (d) Method of Payment. Payment of the Exercise Price may be made at the election of the
Optionee (i) by delivery of cash, certified or cashier’s check, money order or other cash
equivalent acceptable to the Partnership in its discretion, (ii) by a broker-assisted cashless
exercise in accordance with Regulation T of the Board of Governors of the Federal Reserve System
through a brokerage firm approved by the Partnership, or (iii) by a cashless exercise for purposes
of Section 20 of this Agreement, or (iv) a combination of the foregoing.

          (e) Issuance of Units. Upon exercise of the Options in accordance with the terms of this
Agreement, the Partnership will issue to the Optionee or to the brokerage firm specified in the
Optionee’s delivery instructions pursuant to a broker-assisted cashless exercise,

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as the case may be, the number of Units so paid for, in the form of fully paid and nonassessable
Depositary Units representing limited partner interests of the Partnership.

     5. Tax Withholding. The Partnership or General Partner shall have the right to deduct from
the Optionee’s compensation or any other payment of any kind (including by withholding the issuance
of Units) the amount of any federal, state, local or foreign taxes required by law to be withheld
as a result of the grant, vesting, or exercise of the Options in whole or in part; provided,
however, that the value of the Units withheld may not exceed the statutory minimum withholding
amount required by law; provided further that the Optionee may direct the Partnership to withhold
from Units issuable in respect of the Options the number of Units with an aggregate Fair Market
Value as of the date of withholding equal to the statutory minimum withholding amount required by
law.

     For purposes of this Agreement, Fair Market Value means, with respect to a Unit for any
purpose on a particular date, (A) if Units are registered under Section 12(b) or 12(g) of the
Securities Exchange Act of 1934, as amended, and listed for trading on a national exchange or
market, the average, for the 30-day period preceding such date, of: (i) the closing price quoted on
the New York Stock Exchange, the American Stock Exchange, or the Nasdaq National Market, as
applicable; (ii) the last sale price quoted on the Nasdaq SmallCap Market; (iii) the average of the
high bid and low asked prices on the Nasdaq OTC Bulletin Board Service or by the National Quotation
Bureau, Inc.; or (iv) if Units are not quoted by any of the above, the average of the closing bid
and asked prices on the relevant date furnished by a professional market maker for the Units, and
(B) if there are not any quoted bid and asked prices, the value as determined in good faith by the
Board of Directors of the General Partner (the “Board”).

     6. Adjustments for Transactions and Other Events. In the event that the Partnership engages
in:

	 	(a)	 	a split or combination of Units (whether by dividend of Units or
otherwise);
	 
	 	(b)	 	an Excess Dividend; or
	 
	 	(c)	 	an issuance of Units of the Partnership or securities convertible into
or exchangeable for Units of the Partnership, to Mr. Carl C. Icahn or his
affiliates, at a price per Unit less than Partners’ equity per Unit. (For
purposes of calculating Partners’ equity per Unit, (1) Partners’ equity shall
be Partners’ equity as stated in the Partnership’s consolidated financial
statements, prepared in accordance with generally accepted accounting
principles, as of the last day of the most recently completed quarterly
financial period of the Partnership prior to the authorization by the Board of
Directors of the General Partner or any committee thereof of the issuance of
the Units or convertible or exchangeable securities to Mr. Icahn or his
affiliates and (2) Partners’ equity per Unit shall be determined by multiplying
Partners’ equity (as determined in accordance with (1)) by 98.01% (or, if
different, the percentage of Partners’ equity attributable, as of the last day
of such most recently completed quarterly period, to all limited partnership
interests), and dividing the result so obtained by the

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	 	 	 	number of outstanding Units as of the last day of such most recently
completed quarterly period),

then the Board shall, in its reasonable discretion and without the consent of the Optionee, make
such adjustments and modifications to the Options and the terms of this Agreement, including but
not limited to the number or kind of interests covered by the Options, the Exercise Price, or the
manner in which the Options are to be exercised, as the Board reasonably determines to be
appropriate in order to prevent the dilution or enlargement of the benefits or potential benefits
provided in respect of Options under this Agreement.

     The Board is also authorized to make (but shall have no obligation or duty to make), in its
reasonable discretion and without the consent of the Optionee, adjustments in the Options and the
terms of this Agreement in recognition of (i) unusual or nonrecurring events affecting the
Partnership, or the financial statements of the Partnership or any affiliate, or (ii) changes in
applicable laws, regulations, or accounting principles, whenever the Board determines in its
reasonable discretion that such adjustments are appropriate in order to prevent dilution or
enlargement of the benefits or potential benefits provided in respect of Options under this
Agreement. For example, for reasons of illustration and without limiting the authority of the
Board, among other things, in the event that the Partnership is to be combined, by merger or
otherwise, with any other entity, the Board may elect to cause the Options to: (i) accelerate, vest
and become fully exercisable immediately prior to any such event, and to terminate and be cancelled
at the time of the closing of any such transaction if not exercised prior thereto; (ii) be
cancelled in exchange for a payment in cash in an amount equal to the inherent value of the Options
based upon the values attributed to the Partnership in such transaction, as determined in the
reasonable discretion of the Board; or (iii) be assumed by the surviving entity and to thereafter
be exercisable (subject to the vesting and other terms set forth herein) for the type of
consideration received in such transaction by a holder of the Units.

     For the purposes of this Agreement, the term Excess Dividend shall mean the amount, if any, by
which the aggregate dividends, paid to holders of Units from and after January 1, 2005, in either
cash or other property (valued at fair market value as determined by the Board, in its reasonable
discretion) exceeds the Available Amount. For purposes of this Agreement, Available Amount shall
mean an amount, as reasonably estimated by the Board, equal to the combined federal, state and
local income and franchise taxes, including estimated taxes, that would be paid by the Partnership
on the aggregate income of the Partnership for all periods from and after January 1, 2005, if the
Partnership were a corporation organized in Delaware having its sole place of business, in New York
City, which files a separate tax return (together with its consolidated subsidiaries).

     7. The Partnership’s Rights. The existence of the Options shall not affect in any way the
right or power of the Partnership or its partners to engage in any act or activity including
without limitation, making or authorizing any or all adjustments, recapitalizations,
reorganizations or other changes in the Partnership’s capital structure or its business, or any
merger or consolidation of the Partnership, or any issue of Units, limited partner interests,
general partner interests, notes, debentures, preferred or other interests with preference ahead of
or convertible into, options, warrants or subscription rights or otherwise affecting the Options or

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the Units or the rights thereof, or the dissolution or liquidation of the Partnership, or any
sale or transfer of all or any part of the Partnership’s assets or business, or any other
partnership act or proceeding, whether of a similar character or otherwise.

     8. Notices. All notices and other communications made or given pursuant to this Agreement
shall be in writing and shall be sufficiently made or given if hand delivered or mailed by
certified mail, addressed to the Optionee at the address contained in the records of the
Partnership or General Partner, or addressed to the Partnership for the attention of the Secretary
of the General Partner at its principal executive office or, if the receiving party consents in
advance, transmitted and received via telecopy or via such other electronic transmission mechanism
as may be available to the parties.

     9. Investment Representation. If at any time the Partnership determines that the delivery of
Units under this Agreement is or may be unlawful under the laws of any applicable jurisdiction, or
federal or state securities laws, the right to exercise the Options or receive Units pursuant to
the Options or exercise of any particular right hereunder shall be suspended until the Partnership
determines that such delivery is lawful. The Partnership may require that the Optionee, as a
condition to exercise of the Option, and as a condition to the delivery of any Units, make such
written representations (including representations to the effect that such person will not dispose
of the Units so acquired in violation of federal or state securities laws) and furnish such
information as may, in the opinion of counsel for the Partnership, be appropriate to permit the
Partnership to issue the Units in compliance with applicable federal and state securities laws.

     10. Entire Agreement. This Agreement contains the entire agreement between the parties with
respect to the Options granted hereunder. Any oral or written agreements, representations,
warranties, written inducements, or other communications made prior to the execution of this
Agreement with respect to the Options granted hereunder shall be void and ineffective for all
purposes.

     11. Partnership’s Authority. The Partnership shall have full power and authority to interpret
and construe this Agreement and to take all actions necessary to administer and to otherwise carry
out the purpose and intent of this Agreement. All actions taken and determinations made by the
Partnership on all matters relating to this Agreement shall be in the Partnership’s sole and
absolute discretion and shall be conclusive and binding on all parties concerned.

     12. Amendment. This Agreement may be amended from time to time in a written document signed
by each of the parties hereto.

     13. Governing Law. The validity, construction and effect of this Agreement, and of any
determinations or decisions made by the Partnership relating to this Agreement, and the rights of
any and all persons having or claiming to have any interest under this Agreement, shall be
determined exclusively in accordance with the laws of Delaware without regard to its provisions
concerning the applicability of laws of other jurisdictions. Any suit with respect hereto will be
brought in the federal or state courts in the districts which include courts in

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Delaware, and the Optionee hereby agrees and submits to the personal jurisdiction and venue
thereof.

     14. Headings. The headings in this Agreement are for reference purposes only and shall not
affect the meaning or interpretation of this Agreement.

     15. Options Conditioned Upon Unit Holder Approval. This Agreement and the Options are
conditioned upon and subject to approval thereof by a vote of the depositary unit holders in
accordance with rules of the New York Stock Exchange. In the event such approval is not obtained
by December 31 of the year of the Grant Date, this Agreement and the Options shall be null and
void.

     16. Non-Guarantee of Employment or Other Service Relationship. Nothing in this Agreement
shall alter the Optionee’s at-will or other employment status with the Partnership or the General
Partner, nor be construed as a contract of employment or other service relationship between the
Partnership or the General Partner and the Optionee, or as a contractual right of the Optionee to
continue in the employ of, or in a service relationship with (or to occupy any particular position
with, or receive any particular benefit or compensation from the Partnership, and any change
thereof shall not be deemed to constitute a termination of employment hereunder) the Partnership or
the General Partner for any period of time, or as a limitation of the right of the Partnership or
the General Partner to discharge the Optionee at any time with or without cause or notice and
whether or not such discharge results in the forfeiture of any Units.

     17. No Rights as a Holder of a Unit. The Optionee will not have any of the rights of a holder
of a Unit until such Units have been issued to him upon the due exercise of the Options.

     18. Registration of Units. The Options and the Units issuable in connection with the exercise
of the Options shall be registered on a Form S-8 registration statement which also cover the resale
of such Units.

     19. Nontransferability of Options. The Options are nontransferable and may be exercised only
by Optionee except that (a) upon the death of the Optionee, vested Options may be transferred by
will or the laws of descent and distribution or (b) if the Optionee is under a legal disability,
the vested Options may be transferred to the Optionee’s guardian or legal representative. Except
as provided above, the Options may not be assigned, transferred, pledged, hypothecated or disposed
of in any way (whether by operation of law or otherwise) and shall not be subject to execution,
attachment or similar process.

     20. Units No Longer Publicly Traded. In the event that the Units are no longer publicly
traded, the Optionee may exercise the vested Options on a cashless basis, in which event the
Optionee will be paid with respect to each Unit for which the Option is exercised the amount by
which the Fair Market Value of the Unit, on the date of exercise exceeds, the Exercise Price.

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     IN WITNESS WHEREOF, the Partnership has caused this Agreement to be executed this
29th day of June, 2005.

	 	 	 
	 
	 	American Real Estate Partners, L.P.
	 
	 	 
	 
	By:	American Property Investors, Inc.,
its general partner
	 
	 	 
	 

	 	/s/ Jon F. Weber

By: Jon F. Weber
	 

	 	Its: President

     The undersigned hereby acknowledges that he has carefully read this Agreement and agrees to be
bound by all of the provisions set forth herein.

	 	 	 
	WITNESS

	 	OPTIONEE
	 
	 	 
	/s/ Jesse
Lynn

Jesse Lynn

	 	/s/ Keith A. Meister

Keith A. Meister
	 
	 	 
	 

	 	Date: June 29, 2005

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Appendix A

     For purposes of the Agreement, “Change in Control” means the consummation of any transaction
(including, without limitation, any merger or consolidation), the result of which is that any
Person, other than Carl Icahn or the Related Parties, becomes the Beneficial Owner, directly or
indirectly, of more than 50% of the Voting Stock of the Partnership, measured by voting power
rather than number of shares.

For purposes of the definition of Change in Control, the following capitalized terms will
have the following meaning:

     ”Beneficial Owner” has the meaning assigned to such term in Rule 13d-3 and Rule 13d-5
under the Exchange Act, except that in calculating the beneficial ownership of any
particular “person” (as that term is used in Section 13(d)(3) of the Exchange Act), such
“person” will be deemed to have beneficial ownership of all securities that such “person”
has the right to acquire by conversion or exercise of other securities, whether such right
is currently exercisable or is exercisable only after the passage of time. The terms
“Beneficially Owns” and “Beneficially Owned” have a corresponding meaning.

     “Exchange Act” means the Securities Exchange Act of 1934, as amended, and any successor
thereto.

     “Person” means any individual, entity or group within the meaning of Section 13(d)(3)
of the Exchange Act, other than employee benefit plans sponsored or maintained by the
Partnership or by entities controlled by the Partnership.

     “Related Parties” means: (1) Carl Icahn, any spouse and any child, stepchild, sibling
or descendant of Carl Icahn; (2) any estate of Carl Icahn or of any person under clause (1);
(3) any person who receives a beneficial interest in any estate under clause (2) to the
extent of such interest; (4) any executor, personal administrator or trustee who holds such
beneficial interest in the Partnership for the benefit of, or as fiduciary for, any person
under clauses (1), (2) or (3) to the extent of such interest; (5) any corporation,
partnership, limited liability Partnership, trust, or similar entity, directly or indirectly
owned or controlled by Carl Icahn or any other person or persons identified in clauses (1),
(2), (3) or (4) and (6) any not-for-profit entity not subject to taxation pursuant to
Section 501(c)(3) of the Internal Revenue Code or any successor provision to which Carl
Icahn or any person identified in clauses (1), (2), or (3) above contributes his beneficial
interest in the Partnership or to which such beneficial interest passes pursuant to such
person’s will.

     ”Voting Stock” means, with respect to any Person that is (a) a corporation, any class
or series of capital stock of such Person that is ordinarily entitled to vote in the
election of directors thereof at a meeting of stockholders called for such purpose, without
the occurrence of any additional event or contingency, (b) a limited liability company,
membership interests entitled to manage, or to elect or appoint the Persons that will

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manage the operations or business of the limited liability company, or (c) a partnership,
partnership interests entitled to elect or replace the general partner thereof.

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Appendix B

AMERICAN REAL ESTATE PARTNERS, L.P.

OPTION GRANT AGREEMENT EXERCISE FORM

	TO:	 	Secretary of American Real Estate Partners, L.P.

	FROM:	 	 
 

I hereby irrevocably exercise my option to purchase depositary (common) units representing limited
partner interests of American Real Estate Partners, L.P. subject to all the terms and provisions of
the Option Grant Agreement as follows:

	     Date of Option Grant:	 	 
 

	     Date(s) of Vesting of Option:	 	 
 

	     Exercise Price: $35.00 per unit	 	 

	     Number of Units to be Purchased:	 	 
 

	     Total Exercise Price Enclosed: $	 	 
 

     Units should be registered as follows:

	 	o  	 	In Optionee’s name or the name of another individual:

	 	Name(s)	 	 
 

	 	Address	 	 
 

	 	Social Security Number:	 	 
 

	 	o 	 	 In the name of Optionee’s broker
	 	 	 	 

Full payment of the aggregate option exercise price pursuant to Sections 4(c) and (d) of the Option
Grant Agreement is enclosed as follows:

	 	o(i)	 	Cash, certified or cashier’s check, money order or other cash equivalent in the amount of $                    , (number of Units being exercised x grant price per unit)
	 
	 	o(ii)	 	Broker-assisted cashless exercise pursuant to Federal Reserve Regulation T in the amount of $                     (broker is hereby authorized to make such payment directly to American Real Estate Partners, L.P. )
	 
	 	 	 	Contact Information for Broker:

	 	Name	 	 
 

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	 	Address	 	 
 

 
 

	 	Telephone:	 	 
 

Any broker-assisted cashless exercise must be in accordance with Federal
Reserve Regulation T.

	 	 	 	 	 
	 	 	 
	 	 	Optionee’s Signature
	 
	 	 	 	 
	 
	 	Date:	 	 
	 

	 	 	 	 

11exv10w1

 

	 	 	 
	Illini Bank and Illini Corporation

	 	EXHIBIT 10.1

	Supplemental Life Insurance Agreement II
	 	 

 

 

     THIS SUPPLEMENTAL LIFE INSURANCE AGREEMENT (the “Agreement”) is adopted this ___day
of ___, 200___, by and between ILLINI BANK, a state-chartered commercial bank and
ILLINI CORPORATION, a bank holding company located in Springfield, Illinois (the “Bank”), and ___(the
“Executive”).

     The purpose of this Agreement is to retain and reward the Executive, by dividing the death
proceeds of certain life insurance policies which are owned by the Bank on the life of the
Executive with the designated beneficiary of the Executive. The Bank will pay the life insurance
premiums from its general assets.

Article 1

Definitions

Whenever used in this Agreement, the following terms shall have the meanings specified:

	1.1	 	“Bank’s Interest” means the benefit set forth in Section 2.1.
	 
	1.2	 	“Beneficiary” means each designated person, or the estate of the deceased Executive,
entitled to benefits, if any, upon the death of the Executive.
	 
	1.3	 	“Beneficiary Designation Form” means the form established from time to time by the
Plan Administrator that the Executive completes, signs and returns to the Plan Administrator
to designate one or more Beneficiaries.
	 
	1.4	 	“Board” means the Board of Directors of the Bank as from time to time constituted.
	 
	1.5	 	“Change in Control” means a change in the ownership or effective control of the Bank,
or in the ownership of a substantial portion of the assets of the Bank, as such change is
defined in Section 409A of the Code and regulations thereunder.
	 
	1.6	 	“Code” means the Internal Revenue Code of 1986, as amended.
	 
	1.7	 	“Disability” means the Executive (i) is unable to engage in any substantial gainful
activity by reason of any medically determinable physical or mental impairment which can be
expected to result in death or can be expected to last for a continuous period of not less
than twelve (12) months, or (ii) is, by reason of any medically determinable physical or
mental impairment which can be expected to result in death or can be expected to last for a
continuous period of not less than twelve (12) months, receiving income replacement benefits
for a period of not less than three (3) months under an accident and health plan covering
employees of the Bank. Medical determination of Disability may be made by either the Social
Security Administration or by the provider of an accident or health plan covering employees of
the Bank. Upon the request of the Plan Administrator, the Executive must submit proof to the
Plan Administrator of the Social Security Administration’s or provider’s determination.

 

 

Illini Bank and Illini Corporation

Supplemental Life Insurance Agreement 

 

 

	1.8	 	“Executive’s Interest” means the benefit set forth in Section 2.2.
	 
	1.9	 	“Insurer” means the insurance company issuing the Policy on the life of the
Executive.
	 
	1.10	 	“Net Death Proceeds” means the total death proceeds of the Policy minus the greater
of (i) the cash surrender value or (ii) the aggregate premiums paid by the Bank.
	 
	1.11	 	“Plan Administrator” means the plan administrator described in Article 12.
	 
	1.12	 	“Policy” or “Policies” means the individual insurance policy or policies
adopted by the Bank for purposes of insuring the Executive’s life under this Agreement.
	 
	1.13	 	“Separation from Service” means that the Executive’s service, as an employee and
independent contractor, to the Bank and any member of a controlled group as defined in Section
414 of the Code to which the Bank belongs, has terminated for any reason, other than by reason
of a leave of absence approved by the Bank or the death of the Executive.
	 
	1.14	 	“Vested Insurance Benefit” means the Bank will provide the Executive with continued
insurance coverage from the date of vesting until death, subject to the forfeiture provisions
detailed in Section 3.2 and Article 6. Article 3 explains how the Executive achieves vested
status.

Article 2

Policy Ownership/Interests

	2.1	 	Bank’s Interest. The Bank shall own the Policies and shall have the right to
exercise all incidents of ownership and, subject to Article 4, the Bank may terminate a Policy
without the consent of the Executive. The Bank shall be the beneficiary of the remaining
death proceeds of the Policies after the Executive’s Interest is determined according to
Section 2.2 below.
	 
	2.2	 	Executive’s Interest. The Executive, or the Executive’s assignee, shall have the
right to designate the Beneficiary of an amount of death proceeds as specified in Section
2.2.1 or 2.2.2. The Executive shall also have the right to elect and change settlement
options with respect to the Executive’s Interest by providing written notice to the Bank and
the Insurer.

	 	2.2.1	 	Death Prior to Separation from Service. If the Executive dies while
employed by the Bank, the Executive’s Beneficiary shall be entitled to a benefit equal
to One Hundred Twenty-Five Thousand Dollars ($125,000), provided that such benefit
shall not exceed the Net Death Proceeds.
	 
	 	2.2.2	 	Death After Separation from Service. If, pursuant to Article 3, the
Executive has a Vested Insurance Benefit at the date of death, the Executive’s
Beneficiary shall be entitled to a benefit equal to One Hundred Twenty-Five Thousand
Dollars ($125,000), provided that such amount shall not exceed the Net Death Proceeds.

 

 

Illini Bank and Illini Corporation

Supplemental Life Insurance Agreement

 

 

	 	 	 	If the Executive has not achieved a Vested Insurance Benefit on the date of death,
the Beneficiary will not be entitled to a benefit under this Agreement.

Article 3

Vesting

	3.1	 	Vested Insurance Benefit. The Executive shall have a Vested Insurance Benefit equal
to the amount specified in Section 2.2 at the earliest of the following events:

	 	3.1.1	 	Attainment of age sixty-two (62) while in the employ of the Bank
	 
	 	3.1.2	 	Separation from Service due to Disability;
	 
	 	3.1.4	 	A Change of Control while employed by the Bank; or
	 
	 	3.1.5	 	Adoption, by the Board at its discretion, of a resolution entitling the
Executive to the Vested Insurance Benefit in Section 2.2 under circumstances not
otherwise addressed in this Section 3.1.

	3.2	 	Forfeiture of Benefit. Notwithstanding the provisions of Section 3.1, the Executive
will forfeit his or her Vested Insurance Benefit if: (i) the Executive violates any of the
provisions detailed in Article 6; (ii) the Executive vested pursuant to Section 3.1.2 and
becomes gainfully employed by an entity other than the Bank; or (iii) the Executive provides
written notice to the Bank declining further participation in the Agreement.

Article 4

Comparable Coverage

	4.1	 	Insurance Policies. If the Executive has a Vested Insurance Benefit, the Bank may
provide such benefit through the Policies purchased at the commencement of this Agreement, or
may provide comparable insurance coverage to the Executive through whatever means the Bank
deems appropriate. If the Executive waives or forfeits his or her right to the Vested
Insurance Benefit, the Bank shall choose to cancel the Policy or Policies on the Executive, or
may continue such coverage and become the direct beneficiary of the entire death proceeds.
	 
	4.2	 	Offer to Purchase. If the Bank discontinues a Policy while the Executive is employed
by the Bank at the date of discontinuance or while the Executive has a Vested Insurance
Benefit that has not been forfeited, the Bank shall give the Executive at least thirty (30)
days to purchase such Policy. The purchase price shall be the fair market value of the
Policy, as determined under Treasury Reg. §1.61-22(g)(2) or any subsequent applicable
authority. Such notification shall be in writing.

 

Illini Bank and Illini Corporation

Supplemental Life Insurance Agreement

 

 

Article 5

Premiums and Imputed Income

	5.1	 	Premium Payment. The Bank shall pay all premiums due on all Policies.
	 
	5.2	 	Economic Benefit. The Bank shall determine the economic benefit attributable to the
Executive based on the life insurance premium factor for the Executive’s age multiplied by the
aggregate death benefit payable to the Beneficiary. The “life insurance premium factor” is
the minimum factor applicable under guidance published pursuant to Treasury Reg. §
1.61-22(d)(3)(ii) or any subsequent authority .
	 
	5.3	 	Imputed Income. The Bank shall impute the economic benefit to the Executive on an
annual basis, by adding the economic benefit to the Executive’s W-2, or if applicable, Form
1099.

Article 6

General Limitations

	6.1	 	Excess Parachute or Golden Parachute Payment. If the payments and benefits pursuant
to this Agreement, either alone or together with other payments and benefits which the
Executive has the right to receive from the Bank, would constitute an “excess parachute
payment” under Section 280G of the Code, or would be a prohibited golden parachute payment
pursuant to 12 C.F.R. §359.2 and for which the appropriate federal banking agency has not
given written consent to pay pursuant to 12 C.F.R. §359.4, the payments and benefits pursuant
to this Agreement shall be reduced, in the manner determined by the Executive in the case of
the application of Section 280G of the Code, by the amount, if any, which is the minimum
necessary to result in (i) no portion of the payments and benefits under this Agreement being
non-deductible to the Bank pursuant to Section 280G of the Code and subject to the excise tax
imposed under Section 4999 of the Code, and (ii) no adverse consequence to the Bank under or
pursuant to such banking regulations. All benefits payable under this Agreement shall also be
subject to limitations or prohibitions imposed by subsequent changes or amendments to the
cited laws and regulations except to the extent that any benefits payable under this Agreement
are grandfathered or otherwise exempt or excluded from the change or amendment.
	 
	6.2	 	Termination for Cause. Notwithstanding any provision of this Agreement to the
contrary, the Executive shall forfeit any right to a benefit under this Agreement if the Bank
terminates the Executive’s employment for cause. Termination of the Executive’s employment for
“Cause” shall mean termination because of personal dishonesty, willful misconduct, breach of
fiduciary duty involving personal profit, intentional failure to perform stated duties,
willful violation of any law, rule or regulation (other than traffic violations or similar
offenses) or final cease-and-desist order or material breach of any provision of the
Agreement. For purposes of this paragraph, no act or failure to act on the Executive’s part
shall be considered “willful” unless done, or omitted to be done, by the Executive not in good
faith and without reasonable belief that the Executive’s action or omission was in the best
interest of the Bank.

 

Illini Bank and Illini Corporation

Supplemental Life Insurance Agreement

 

 

	6.3	 	Removal. Notwithstanding any provision of this Agreement to the contrary, the
Executive’s rights in the Agreement shall terminate if the Executive is subject to a final
removal or prohibition order issued by an appropriate federal banking agency pursuant to
Section 8(e) of the Federal Deposit Insurance Act (“FDIA”).
	 
	6.4	 	Non-compete Provision. The Executive shall forfeit any rights and benefits under
this Agreement if during the term of this Agreement the Executive, directly or indirectly,
either as an individual or as a proprietor, stockholder, partner, officer, director, employee,
agent, consultant or independent contractor of any individual, partnership, corporation or
other entity (excluding an ownership interest of three percent (3%) or less in the stock of a
publicly-traded company):

	 	(i)	 	becomes employed by, participates in, or becomes connected in
any manner with the ownership, management, operation or control of any bank,
savings and loan or other similar financial institution if the Executive’s
responsibilities will include providing banking or other financial services
within the twenty-five (25) miles of any office maintained by the Bank as of
the date of the termination of the Executive’s employment;
	 
	 	(ii)	 	participates in any way in hiring or otherwise engaging, or
assisting any other person or entity in hiring or otherwise engaging, on a
temporary, part-time or permanent basis, any individual who was employed by the
Bank as of the date of termination of the Executive’s employment;
	 
	 	(iii)	 	assists, advises, or serves in any capacity, representative or
otherwise, any third party in any action against the Bank or transaction
involving the Bank;
	 
	 	(iv)	 	sells, offers to sell, provides banking or other financial
services, assists any other person in selling or providing banking or other
financial services, or solicits or otherwise competes for, either directly or
indirectly, any orders, contract, or accounts for services of a kind or nature
like or substantially similar to the financial services performed or financial
products sold by the Bank (the preceding hereinafter referred to as
“Services”), to or from any person or entity from whom the Executive or the
Bank, to the knowledge of the Executive provided banking or other financial
services, sold, offered to sell or solicited orders, contracts or accounts for
Services during the three (3) year period immediately prior to the termination
of the Executive’s employment;
	 
	 	(v)	 	divulges, discloses, or communicates to others in any manner
whatsoever, any confidential information of the Bank, to the knowledge of the
Executive, including, but not limited to, the names and addresses of customers
or prospective customers, of the Bank, as they may have existed from time to
time, of work performed or services rendered for any customer, any method
and/or procedures relating to projects or other work developed

 

Illini Bank and Illini Corporation

Supplemental Life Insurance Agreement

 

 

	 	 	 	for the Bank,
earnings or other information concerning the Bank. The restrictions contained
in this subparagraph (v) apply to all information
regarding the Bank, regardless of the source who provided or compiled such
information. Notwithstanding anything to the contrary, all information
referred to herein shall not be disclosed unless and until it becomes known to
the general public from sources other than the Executive.

	 	6.4.1	 	Judicial Remedies. In the event of a breach or threatened breach by
the Executive of any provision of these restrictions, the Executive recognizes the
substantial and immediate harm that a breach or threatened breach will impose upon the
Bank, and further recognizes that in such event monetary damages may be inadequate to
fully protect the Bank. Accordingly, in the event of a breach or threatened breach of
these restrictions, the Executive consents to the Bank’s entitlement to such ex
parte, preliminary, interlocutory, temporary or permanent injunctive, or any
other equitable relief, protecting and fully enforcing the Bank’s rights hereunder and
preventing the Executive from further breaching any of his obligations set forth
herein. The Executive expressly waives any requirement, based on any statute, rule of
procedure, or other source, that the Bank post a bond as a condition of obtaining any
of the above-described remedies. Nothing herein shall be construed as prohibiting the
Bank from pursuing any other remedies available to the Bank at law or in equity for
such breach or threatened breach, including the recovery of damages from the Executive.
The Executive expressly acknowledges and agrees that: (i) the restrictions set forth
in Section 6.4 hereof are reasonable, in terms of scope, duration, geographic area, and
otherwise, (ii) the protections afforded the Bank in Section 6.4 hereof are necessary
to protect its legitimate business interest, (iii) the restrictions set forth in
Section 6.4 hereof will not be materially adverse to the Executive’s employment with
the Bank, and (iv) his agreement to observe such restrictions forms a material part of
the consideration for this Agreement.
	 
	 	6.4.2	 	Overbreadth of Restrictive Covenant. It is the intention of the
parties that if any restrictive covenant in this Agreement is determined by a court of
competent jurisdiction to be overly broad, then the court should enforce such
restrictive covenant to the maximum extent permitted under the law as to area, breadth
and duration.
	 
	 	6.4.3	 	Change in Control. The non-compete provision detailed in Section 6.4
hereof shall not be enforceable following a Change in Control.

	6.5	 	Suicide or Misstatement. No benefits shall be payable if the Executive commits
suicide within two years after the date of this Agreement, or if the insurance company denies
coverage (i) for material misstatements of fact made by the Executive on any application for
life insurance purchased by the Bank, or (ii) for any other reason; provided, however that the
Bank shall evaluate the reason for the denial, and upon advice of legal counsel and in its
sole discretion, consider judicially challenging any denial.

 

Illini Bank and Illini Corporation

Supplemental Life Insurance Agreement

 

 

Article 7

Beneficiaries

	7.1	 	Beneficiary. The Executive shall have the right, at any time, to designate a
Beneficiary(ies) to receive any benefits payable under the Agreement upon the death of the
Executive. The Beneficiary designated under this Agreement may be the same as or different
from the beneficiary designation under any other Agreement of the Bank in which the Executive
participates.
	 
	7.2	 	Beneficiary Designation; Change. The Executive shall designate a Beneficiary by
completing and signing the Beneficiary Designation Form, and delivering it to the Bank or its
designated agent. The Executive’s beneficiary designation shall be deemed automatically
revoked if the Beneficiary predeceases the Executive or if the Executive names a spouse as
Beneficiary and the marriage is subsequently dissolved. The Executive shall have the right to
change a Beneficiary by completing, signing and otherwise complying with the terms of the
Beneficiary Designation Form and the Bank’s rules and procedures, as in effect from time to
time. Upon the acceptance by the Bank of a new Beneficiary Designation Form, all Beneficiary
designations previously filed shall be cancelled. The Bank shall be entitled to rely on the
last Beneficiary Designation Form filed by the Executive and accepted by the Bank prior to the
Executive’s death.
	 
	7.3	 	Acknowledgment. No designation or change in designation of a Beneficiary shall be
effective until received, accepted and acknowledged in writing by the Bank or its designated
agent.
	 
	7.4	 	No Beneficiary Designation. If the Executive dies without a valid designation of
beneficiary, or if all designated Beneficiaries predecease the Executive, then the Executive’s
surviving spouse shall be the designated Beneficiary. If the Executive has no surviving
spouse, the benefits shall be made payable to the personal representative of the Executive’s
estate.
	 
	7.5	 	Facility of Payment. If the Bank determines in its discretion that a benefit is to
be paid to a minor, to a person declared incompetent, or to a person incapable of handling the
disposition of that person’s property, the Bank may direct payment of such benefit to the
guardian, legal representative or person having the care or custody of such minor, incompetent
person or incapable person. The Bank may require proof of incompetence, minority or
guardianship as it may deem appropriate prior to distribution of the benefit. Any payment of
a benefit shall be a payment for the account of the Executive and the Executive’s Beneficiary,
as the case may be, and shall be a complete discharge of any liability under the Agreement for
such payment amount.

Article 8

Assignment

          The Executive may irrevocably assign without consideration all of the Executive’s Interest in
this Agreement to any person, entity, or trust. In the event the Executive shall transfer

 

Illini Bank and Illini Corporation

Supplemental Life Insurance Agreement

 

 

all of
the Executive’s Interest, then all of the Executive’s Interest in this Agreement shall be vested in
the Executive’s transferee, who shall be substituted as a party hereunder, and the Executive shall
have no further interest in this Agreement.

Article 9

Insurer

          The Insurer shall be bound only by the terms of its given Policy. The Insurer shall not be
bound by or deemed to have notice of the provisions of this Agreement. The Insurer shall have the
right to rely on the Bank’s representations with regard to any definitions, interpretations or
Policy interests as specified under this Agreement.

Article 10

Claims And Review Procedure

	10.1	 	Claims Procedure. The Executive or Beneficiary (“claimant”) who has not received
benefits under the Agreement that he or she believes should be paid shall make a claim for
such benefits as follows:

	 	10.1.1	 	Initiation – Written Claim. The claimant initiates a claim by submitting to
the Bank a written claim for the benefits.
	 
	 	10.1.2	 	Timing of Bank Response. The Bank shall respond to such claimant within 90
days after receiving the claim. If the Bank determines that special circumstances
require additional time for processing the claim, the Bank can extend the response
period by an additional 90 days by notifying the claimant in writing, prior to the end
of the initial 90-day period, that an additional period is required. The notice of
extension must set forth the special circumstances and the date by which the Bank
expects to render its decision.
	 
	 	10.1.3	 	Notice of Decision. If the Bank denies part or all of the claim, the Bank
shall notify the claimant in writing of such denial. The Bank shall write the
notification in a manner calculated to be understood by the claimant. The notification
shall set forth:

	 	(a)	 	The specific reasons for the denial;
	 
	 	(b)	 	A reference to the specific provisions of the Agreement on
which the denial is based;
	 
	 	(c)	 	A description of any additional information or material
necessary for the claimant to perfect the claim and an explanation of why it is
needed;
	 
	 	(d)	 	An explanation of the Agreement’s review procedures and the
time limits applicable to such procedures; and
	 
	 	(e)	 	A statement of the claimant’s right to bring a civil action
under ERISA Section 502(a) following an adverse benefit determination on
review.

 

Illini Bank and Illini Corporation

Supplemental Life Insurance Agreement

 

 

	10.2	 	Review Procedure. If the Bank denies part or all of the claim, the claimant shall
have the opportunity for a full and fair review by the Bank of the denial, as follows:

	 	10.2.1	 	Initiation – Written Request. To initiate the review, the claimant, within
60 days after receiving the Bank’s notice of denial, must file with the Bank a written
request for review.
	 
	 	10.2.2	 	Additional Submissions – Information Access. The claimant shall then have
the opportunity to submit written comments, documents, records and other information
relating to the claim. The Bank shall also provide the claimant, upon request and free
of charge, reasonable access to, and copies of, all documents, records and other
information relevant (as defined in applicable ERISA regulations) to the claimant’s
claim for benefits.
	 
	 	10.2.3	 	Considerations on Review. In considering the review, the Bank shall take
into account all materials and information the claimant submits relating to the claim,
without regard to whether such information was submitted or considered in the initial
benefit determination.
	 
	 	10.2.4	 	Timing of Bank’s Response. The Bank shall respond in writing to such
claimant within 60 days after receiving the request for review. If the Bank determines
that special circumstances require additional time for processing the claim, the Bank
can extend the response period by an additional 60 days by notifying the claimant in
writing, prior to the end of the initial 60-day period, that an additional period is
required. The notice of extension must set forth the special circumstances and the
date by which the Bank expects to render its decision.
	 
	 	10.2.5	 	Notice of Decision. The Bank shall notify the claimant in writing of its
decision on review. The Bank shall write the notification in a manner calculated to be
understood by the claimant. The notification shall set forth:

	 	(a)	 	The specific reasons for the denial;
	 
	 	(b)	 	A reference to the specific provisions of the Agreement on
which the denial is based;
	 
	 	(c)	 	A statement that the claimant is entitled to receive, upon
request and free of charge, reasonable access to, and copies of, all documents,
records and other information relevant (as defined in applicable ERISA
regulations) to the claimant’s claim for benefits; and
	 
	 	(d)	 	A statement of the claimant’s right to bring a civil action
under ERISA Section 502(a).

 

Illini Bank and Illini Corporation

Supplemental Life Insurance Agreement

 

 

Article 11

Amendments And Termination

	11.1	 	Non-Vested Insurance Benefit. Unless the Executive has a Vested Insurance Benefit
pursuant to Section 3.1, the Bank may amend or terminate the Agreement at any time, or may
amend or terminate the Executive’s rights under the Agreement at any time prior to
the Executive’s death, by providing written notice of such to the Executive. In the event
that the Bank decides to maintain the Policy after termination of the Agreement, the Bank
shall be the direct beneficiary of the entire death proceeds of the Policy.
	 
	11.2	 	Vested Insurance Benefit. If the Executive has a Vested Insurance Benefit, the Bank
may amend or terminate the Agreement only if: (i) continuation of the Agreement would cause
significant financial harm to the Bank, (ii) the Executive agrees to such action, or (iii) the
Bank’s banking regulator(s) issues a written directive to amend or terminate the Agreement.

Article 12

Administration

	12.1	 	Plan Administrator Duties. This Agreement shall be administered by a Plan
Administrator which shall consist of the Board, or such committee or persons as the Board may
choose. The Plan Administrator shall also have the discretion and authority to (i) make,
amend, interpret and enforce all appropriate rules and regulations for the administration of
this Agreement and (ii) decide or resolve any and all questions including interpretations of
this Agreement, as may arise in connection with this Agreement.
	 
	12.2	 	Agents. In the administration of this Agreement, the Plan Administrator may employ
agents and delegate to them such administrative duties as it sees fit, (including acting
through a duly appointed representative), and may from time to time consult with counsel who
may be counsel to the Bank.
	 
	12.3	 	Binding Effect of Decisions. The decision or action of the Plan Administrator with
respect to any question arising out of or in connection with the administration,
interpretation and application of this Agreement and the rules and regulations promulgated
hereunder shall be final and conclusive and binding upon all persons having any interest in
this Agreement.
	 
	12.4	 	Indemnity of Plan Administrator. The Bank shall indemnify and hold harmless the
members of the Plan Administrator against any and all claims, losses, damages, expenses or
liabilities arising from any action or failure to act with respect to this Agreement, except
in the case of willful misconduct by the Plan Administrator or any of its members.

 

Illini Bank and Illini Corporation

Supplemental Life Insurance Agreement

 

 

	12.5	 	Information. To enable the Plan Administrator to perform its functions, the Bank
shall supply full and timely information to the Plan Administrator on all matters relating to
the Base Salary of the Executive, the date and circumstances of the retirement, Disability,
death or Separation from Service of the Executive, and such other pertinent information as the
Plan Administrator may reasonably require.

Article 13

Miscellaneous

	13.1	 	Binding Effect. This Agreement shall bind the Executive and the Bank, their
beneficiaries, survivors, executors, administrators and transferees and any Beneficiary.
	 
	13.2	 	No Guarantee of Employment. This Agreement is not an employment policy or contract.
It does not give the Executive the right to remain an Executive of the Bank, nor does it
interfere with the Bank’s right to discharge the Executive. It also does not require the
Executive to remain an Executive nor interfere with the Executive’s right to terminate
employment at any time.
	 
	13.3	 	Applicable Law. The Agreement and all rights hereunder shall be governed by and
construed according to the laws of the state of Illinois, except to the extent preempted by
the laws of the United States of America.
	 
	13.4	 	Reorganization. The Bank shall not merge or consolidate into or with another
company, or reorganize, or sell substantially all of its assets to another company, firm or
person unless such succeeding or continuing company, firm or person agrees to assume and
discharge the obligations of the Bank under this Agreement. Upon the occurrence of such
event, the term “Bank” as used in this Agreement shall be deemed to refer to the successor or
survivor company.
	 
	13.5	 	Notice. Any notice or filing required or permitted to be given to the Bank under
this Agreement shall be sufficient if in writing and hand-delivered, or sent by registered or
certified mail, to the address below:

	 
	Illini Bank

	
3200
West Iles Avenue

	
P O Box 13257

	Springfield,
Illinois 62711

Such notice shall be deemed given as of the date of delivery or, if delivery is made by
mail, as of the date shown on the postmark or the receipt for registration or certification.

Any notice or filing required or permitted to be given to the Executive under this Agreement
shall be sufficient if in writing and hand-delivered, or sent by mail, to the last known
address of the Executive.

 

Illini Bank and Illini Corporation

Supplemental Life Insurance
Agreement

 

 

	13.6	 	Entire Agreement. This Agreement, along with the Executive’s Beneficiary Designation
Form, constitutes the entire agreement between the Bank and the Executive as to the subject
matter hereof. No rights are granted to the Executive under this Agreement other than those
specifically set forth herein.

     IN WITNESS WHEREOF, the parties have executed this Agreement as of the date indicated above.

	 	 	 	 	 
	EXECUTIVE:	 	ILLINI BANK
	 
	 	 	 	 
	 

	 	By	 	 
	 

	 	 	 	 
	 
	 	 	 	 
	 

	 	Title	 	 
	 

	 	 	 	 
	 
	 	 	 	 
	 
	 	 	 	 
	 	 	ILLINI CORPORATION
	 
	 	 	 	 
	 

	 	By	 	 
	 

	 	 	 	 
	 
	 	 	 	 
	 

	 	Title	 	 
	 

	 	 	 	 

 

Illini Bank and Illini Corporation

Supplemental Life Insurance Agreement

 

 

	 	 	 
	{  }

{  }

	 	New Designation

Change in Designation

I, ___________________, designate the following as Beneficiary under the Agreement:

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 
	 	 

	 	Primary:	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	%	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	%	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	%	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 
	 	 

	 	Contingent:	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	%	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	%	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	%	 	 	 	 	 	 
	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 

Notes:

	 	•	 	Please PRINT CLEARLY or TYPE the names of the beneficiaries.
	 
	 	•	 	To name a trust as beneficiary, please provide the name of the trustee(s) and the
exact name and date of the trust agreement.
	 
	 	•	 	To name your estate as beneficiary, please write “Estate of _[your name]_”.
	 
	 	•	 	Be aware that none of the contingent beneficiaries will receive anything unless ALL of
the primary beneficiaries predecease you.

I understand that I may change these beneficiary designations by delivering a new written
designation to the Administrator, which shall be effective only upon receipt and acknowledgment by
the Administrator prior to my death. I further understand that the designations will be
automatically revoked if the beneficiary predeceases me, or, if I have named my spouse as
beneficiary and our marriage is subsequently dissolved.

	 	 	 	 	 	 	 
	Name:
	 	 	 	 	 	 
	 

	 	 	 	 	 	 
	 
	 	 	 	 	 	 
	Signature:

	 	 	 	Date:	 	 
	 

	 	 
	 	 	 	 
	 
	 	 	 	 	 	 

Received by the Plan Administrator this ________ day of ___________________, 2___

	 	 	 
	By:
	 	 
	 

	 	 
	 
	 	 
	Title:

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