Document:

ex10-1.htm

    Exhibit
      10.1

     

    
      SELECTIVE
        INSURANCE GROUP, INC.

       

      2005
        OMNIBUS STOCK PLAN

       

      RESTRICTED
        STOCK UNIT AGREEMENT

       

      This
        RESTRICTED STOCK UNIT AGREEMENT (the “Restricted
        Stock Unit Agreement”) is made and entered into as of [DATE] (the “Date
        of
        Grant”), by and between Selective Insurance Group, Inc., a New Jersey
        corporation (the “Company”)
        and [EMPLOYEE] (the “Recipient”).

       

      WHEREAS,
        the Salary and Employee Benefits Committee (the “Committee”)
        of the Board of Directors of the Company (the “Board”)
        has approved the grant of Restricted Stock Units pursuant to the Selective
        Insurance Group, Inc. 2005 Omnibus Stock Plan, as amended (the “Plan”),
        as hereinafter defined, to the Recipient as set forth below;

       

      NOW,
        THEREFORE, in consideration of the covenants and agreements herein contained,
        and intending to be legally bound hereby, the parties agree as follows:

       

      1.        Definitions.  Capitalized
        terms which are not defined herein shall have the meanings set forth in the
        Plan.

       

      2.        Grant
        of
        Restricted Stock Units.  The Company hereby grants to the
        Recipient an award of [NUMBER] Restricted Stock Units, subject to all of
        the
        terms and conditions of this Restricted Stock Unit Agreement and the
        Plan.

       

      3.        Lapse
        of
        Restrictions.  All Restricted Stock Units shall vest as set
        forth in this Section 3, and, except as herein provided, shall be forfeited
        upon
        the Recipient’s termination of employment with the Company and all its
        Subsidiaries.  The Restricted Stock Units shall become vested
        if:

       

      (a)           
        the Recipient is employed by the Company or any Subsidiary as of the applicable
        anniversary date set forth below (the “Vesting
        Date”); and

       

      (b)           
        [satisfaction of performance goals].

       

      
        	
                 

              	
                Notwithstanding
                  the foregoing, the Restricted Stock Units shall not be forfeited
                  if the
                  Recipient terminates employment with the Company and all its Subsidiaries
                  prior to the Vesting Date solely as a result of the Recipient’s death,
                  termination of employment on or after “Early Retirement Age” or “Normal
                  Retirement Age,” as each is defined in the Retirement Income Plan for
                  Selective Insurance Company of America (the “Retirement
                  Income Plan”), or “Total Disability” as defined in the Retirement
                  Income Plan.  However, except where the Recipient dies
                  

              

      

       

       

      Restricted
        Stock Unit Agreement (Performance Based)

       

       

      
        
           

        

        
           

          
            

          

        

        
           

        

      

       

       

      while
        still employed by the Company or a Subsidiary, the Recipient
        shall not vest in any of his Restricted Stock Units unless the performance
        goals
        set forth in paragraph (b) are satisfied. 

       

      
        	
                Date

              	
                Percentage
                  Vested

              
	
                [Third
                  anniversary of the Date of Grant]

              	
                [100%]1

              
	 	 

      

      4.        Dividend
        Equivalents.  Following the vesting of a Restricted Stock Unit,
        the Recipient shall also be entitled to receive the Fair Market Value of
        that
        number of shares of Company Stock that would have been payable had the aggregate
        dividends paid with respect to a share of Company Stock during the period
        commencing on the date of grant of the Restricted Stock Unit and terminating
        on
        the date on which the Recipient is entitled to settlement of such Restricted
        Stock Unit pursuant to Section 6 of this Restricted Stock Unit Agreement
        (that
        is, on the Vesting Date, the Recipient’s date of death, the Recipient’s
        Separation from Service or the first business day following the expiration
        of
        six months following the Recipient’s Separation from Service, as applicable)
        been immediately reinvested in Company Stock on the dividend payment
        date.  All such dividend equivalents shall be subject to the same
        vesting and forfeiture requirements as apply to the Restricted Stock Units,
        and
        shall be paid to the Recipient in shares of Company Stock (with any fractional
        shares paid in cash) in accordance with, and at the same time as, settlement
        of
        the vested Restricted Stock Units to which they are related.

       

      5.        Restrictions
        on Transfer.  The Restricted Stock Units may not be sold,
        assigned, hypothecated, pledged or otherwise transferred or encumbered in
        any
        manner except (i) by will or the laws of descent and distribution or (ii)
        as may
        be permitted by the Committee pursuant to Section 22(c) of the Plan.

       

      6.        Settlement
        of Restricted Stock Units.

       

      (a)           
        Subject to the provisions of Section 15 of the Plan and this Section 6, the
        Company shall deliver to the Recipient (or, if applicable, the Recipient’s
        Designated Beneficiary or legal representative) that number of shares of
        Company
        Stock as is equal to the number of Restricted Stock Units covered by this
        Restricted Stock Unit Agreement that have become vested and nonforfeitable
        as
        soon as administratively practicable after the Vesting Date but in no event
        later than the end of the calendar year in which the Vesting Date occurs.

       

      (b)           
        Notwithstanding paragraph (a) of this Section 6, if the Recipient dies prior
        to
        the Vesting Date while still employed by the Company or any of its Subsidiaries,
        then the Recipient shall be immediately vested in all his Restricted Stock
        Units
        and the Company shall deliver to the Recipient (or, if applicable, the
        Recipient’s Designated Beneficiary or legal representative) that number of
        shares of Company Stock as is equal to the number of Restricted Stock Units
        covered by this Restricted Stock Unit Agreement as soon as administratively
        

       

       

      
      

      
        	 	 	 	 	 	 

      

       

      1    [Actual
        dates and
        vesting percentages to be determined by the Committee at the time of
        grant.]

       

       

      
        
           

        

        
          2

          
            

          

        

        
           

        

      

       

       

      practicable
        after the Recipient’s death, but in no event later than the end of the calendar
        year in which such death occurs.

       

      (c)           
        If the Recipient is (or is reasonably expected to be) a “covered employee”
within the meaning of Section 162(m) of the Code for the calendar year in
        which
        delivery of Company Stock and/or payment of dividend equivalents would
        ordinarily be made to the Recipient, the Company may delay delivery to the
        Recipient of that portion of the shares of Company Stock and/or the payment
        of
        that portion of the dividend equivalents for which the Company reasonably
        believes that Section 162(m) of the Code will preclude the Company from taking
        a
        compensation expense deduction, until the Recipient’s “separation from service,”
as such term is defined in Section 409A of the Code and Treas. Reg. Section
        1.409A-1(h), from the Company (“Separation from
        Service”).  Notwithstanding the foregoing, if the Recipient is a
“specified employee,” as such term is defined in Section 409A of the Code and
        Treas. Reg. Section 1.409A-1(i), of the Company at the time of his Separation
        from Service, then such delayed delivery of Company Stock or payment of dividend
        equivalents shall be made on the first business day following the expiration
        of
        six months following the Recipient’s Separation from Service.

       

      7.        
        No
        Rights as a Shareholder.  Until shares of Company Stock are
        issued, if at all, in satisfaction of the Company’s obligations under this
        Restricted Stock Unit Agreement, the Recipient shall have no rights as a
        shareholder.

       

      8.        
        Notices. 
        Any notice required or permitted under this Restricted Stock Agreement shall
        be
        deemed given when delivered personally, or when deposited in a United States
        Post Office, postage prepaid, addressed, as appropriate, to the Recipient
        either
        at the Recipient’s address as last known by the Company or such other address as
        the Recipient may designate in writing to the Company.

       

      9.        
        Securities
        Laws Requirements.  The Company shall not be obligated to transfer
        any shares of Company Common Stock issued in settlement of this Restricted
        Stock
        Unit grant from the Recipient to another party, if such transfer, in the
        opinion
        of counsel for the Company, would violate the Securities Act of 1933, as
        amended
        from time to time (or any other federal or state statutes having similar
        requirements as may be in effect at that time).  Further, the Company
        may require as a condition of transfer of any shares to the Recipient that
        the
        Recipient furnish a written representation that he or she is holding the
        shares
        for investment and not with a view to resale or distribution to the
        public.

       

      10.      
        Protections
        Against Violations of Constituent Documents.  No purported sale,
        assignment, mortgage, hypothecation, transfer, pledge, encumbrance, gift,
        transfer in trust (voting or other) or other disposition of, or creation
        of a
        security interest in or lien on, any of the shares of Company Stock deliverable
        following the vesting of the Restricted Stock Units by any holder thereof
        in
        violation of the provisions of the Certificate of Incorporation or the By-Laws
        of the Company, shall be valid, and the Company will not transfer any of
        said
        shares of Company Stock on its books nor will the holder of any of said Company
        Stock be entitled to vote, nor will any dividends be paid thereon, unless
        and
        until there has been full compliance with said provisions to the satisfaction
        of
        the Company.  The foregoing restrictions are in addition to and not in
        lieu of any other remedies, legal or equitable, available to enforce said
        provisions.

       

       

      
        
           

        

        
          3

          
            

          

        

        
           

        

      

       

       

      11.      
        Taxes.  The
        obligations of the Company under this Restricted Stock Unit Agreement shall
        be
        conditional on satisfaction of the Company’s legal tax withholding obligations
        and, unless the Recipient has made alternative arrangements satisfactory
        to the
        Company with respect to such tax withholding obligations, the Company will
        (1)
        withhold from the shares of Company Stock otherwise deliverable hereunder
        such
        number of shares as it determines is necessary to satisfy all applicable
        withholding tax obligations in respect of such shares, or (2) to the extent
        permitted by law, deduct any such taxes from any payment of any kind otherwise
        due to the Recipient by the Company.

       

       

      12.      
        Failure
        to
        Enforce Not a Waiver.  The failure of the Company to enforce at any
        time any provision of this Restricted Stock Agreement shall in no way be
        construed to be a waiver of such provision or of any other provision
        hereof.

       

      13.      
        Governing
        Law.  This Restricted Stock Unit Agreement shall be governed by and
        construed according to the laws of the State of New Jersey without regard
        to its
        principles of conflict of laws.

       

      14.      
        Amendments. 
        Except as otherwise provided in Section 16, this Restricted Stock Unit Agreement
        may be amended or modified at any time only by an instrument in writing signed
        by each of the parties hereto.

       

      15.      
        Survival
        of
        Terms.  This Restricted Stock Unit Agreement shall apply to and bind
        the Recipient and the Company and their respective permitted assignees and
        transferees, heirs, legatees, executors, administrators and legal
        successors.

       

      16.      
        Agreement
        Not a Contract for Services.  Neither the grant of Restricted Stock
        Unit, the execution of this Restricted Stock Unit Agreement nor any other
        action
        taken pursuant to this Restricted Stock Unit Agreement shall constitute or
        be
        evidence of any agreement or understanding, express or implied, that the
        Recipient has a right to continue to provide services as an officer, director,
        employee or consultant of the Company for any period of time or at any specific
        rate of compensation.

       

      17.      
        Severability. 
        If a provision of this Restricted Stock Unit Agreement is held invalid by
        a
        court of competent jurisdiction, the remaining provisions will nonetheless
        be
        enforceable according to their terms.  Further, if any provision is
        held to be over broad as written, that provision shall be amended to narrow
        its
        application to the extent necessary to make the provision enforceable according
        to applicable law and enforced as amended.

       

      18.      
        Incorporation
        of Plan; Acknowledgment.  The Restricted Stock Unit Award is granted
        pursuant to the Plan, and the Restricted Stock Units and this Restricted
        Stock
        Unit Agreement are in all respects governed by the Plan and subject to all
        of
        the terms and provisions thereof, whether such terms and provisions are
        incorporated in this Restricted Stock Unit Agreement by reference or are
        expressly cited.  By signing this Restricted Stock Agreement, the
        Recipient acknowledges having received and read a copy of the
        Plan.

       

       

      
        
           

        

        
          4

          
            

          

        

        
           

        

      

       

       

       
        IN WITNESS
        WHEREOF, the parties hereto have executed and delivered this Restricted Stock
        Unit Agreement on the day and year first above written.

       

       

       

      
        	 	 	
                SELECTIVE
                  INSURANCE GROUP, INC.

                 

              
	 	 	
                By:

              
	 	 	
                Title:

                 

              
	 	 	 	
                 

                 

              
	 	 	
                [EMPLOYEE]

                 

              
	 	 	 	
                 

                 

              
	 	 	
                [CURRENT
                  DATE]

                 

              

      

       

       

      
 

      5ex10-2.htm

     

    
       

      Exhibit
        10.2

       

      SELECTIVE
        INSURANCE
        GROUP, INC.

      2005
        OMNIBUS STOCK PLAN

      RESTRICTED
        STOCK UNIT AGREEMENT

       

      This
        RESTRICTED STOCK UNIT AGREEMENT (the “Restricted
        Stock Unit Agreement”) is made and entered into as of [DATE] (the “Date
        of
        Grant”), by and between Selective Insurance Group, Inc., a New Jersey
        corporation (the “Company”)
        and [EMPLOYEE] (the “Recipient”).

       

      WHEREAS,
        the Salary and Employee Benefits Committee (the “Committee”)
        of the Board of Directors of the Company (the “Board”)
        has approved the grant of Restricted Stock Units pursuant to the Selective
        Insurance Group, Inc. 2005 Omnibus Stock Plan, as amended (the “Plan”),
        as hereinafter defined, to the Recipient as set forth below;

       

      NOW,
        THEREFORE, in consideration of the covenants and agreements herein contained,
        and intending to be legally bound hereby, the parties agree as
        follows:

       

      1.    Definitions.  Capitalized
        terms which are not defined herein shall have the meanings set forth in the
        Plan. 

       

      2.    Grant
        of
        Restricted Stock Units.  The Company hereby grants to the
        Recipient an award of [NUMBER] Restricted Stock Units, subject to all of
        the
        terms and conditions of this Restricted Stock Unit Agreement and the
        Plan. 

       

      3.    Lapse
        of
        Restrictions.  All Restricted Stock Units shall vest as set
        forth in this Section 3, and, except as herein provided, shall be forfeited
        upon
        the Recipient’s termination of employment with the Company and all its
        Subsidiaries.  The Restricted Stock Units shall become vested if the
        Recipient is employed by the Company or any Subsidiary as of the applicable
        anniversary date set forth below (the “Vesting
        Date”).  Notwithstanding the foregoing, the Restricted Stock
        Units shall not be forfeited and the Recipient shall be vested in the Restricted
        Stock Units if the Recipient terminates employment with the Company and all
        its
        Subsidiaries prior to the Vesting Date solely as a result of the Recipient’s
        death, termination of employment on or after “Early Retirement Age” or “Normal
        Retirement Age,” as each is defined in the Retirement Income Plan for Selective
        Insurance Company of America (the “Retirement
        Income Plan”), or “Total Disability” as defined in the Retirement Income
        Plan. 

       

      
        	 	
                Date

              	
                Percentage
                  Vested

              
	 	
                [Third
                  anniversary of the Date of Grant]

              	
                [100%]1

              

      

       

       

      
      

      
        	 	 	 	 	 	 

      

       

      
        1           
          [Actual dates and vesting percentages to be determined by the Committee
          at the
          time of grant.]

         

        Restricted
          Stock Unit Agreement

      

       

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

       

      4.    Dividend
        Equivalents.  Following the vesting of a Restricted Stock Unit,
        the Recipient shall also be entitled to receive the Fair Market Value of
        that
        number of shares of Company Stock that would have been payable had the aggregate
        dividends paid with respect to a share of Company Stock during the period
        commencing on the date of grant of the Restricted Stock Unit and terminating
        on
        the date on which the Recipient is entitled to settlement of such Restricted
        Stock Unit pursuant to Section 6 of this Restricted Stock Unit Agreement
        (that
        is, on the Vesting Date, the Recipient’s Separation from Service or the first
        business day following the expiration of six months following the Recipient’s
        Separation from Service, as applicable) been immediately reinvested in Company
        Stock on the dividend payment date.  All such dividend equivalents
        shall be subject to the same vesting and forfeiture requirements as apply
        to the
        Restricted Stock Units, and shall be paid to the Recipient in shares of Company
        Stock (with any fractional shares paid in cash) in accordance with, and at
        the
        same time as, settlement of the vested Restricted Stock Units to which they
        are
        related. 

       

      5.    Restrictions
        on Transfer.  The Restricted Stock Units may not be sold,
        assigned, hypothecated, pledged or otherwise transferred or encumbered in
        any
        manner except (i) by will or the laws of descent and distribution or (ii)
        as may
        be permitted by the Committee pursuant to Section 22(c) of the
        Plan. 

       

      6.    Settlement
        of Restricted Stock Units. 

       

      (a)    Subject
        to the provisions of
        Section 15 of the Plan and this Section 6, the Company shall deliver to the
        Recipient (or, if applicable, the Recipient’s Designated Beneficiary or legal
        representative) that number of shares of Company Stock as is equal to the
        number
        of Restricted Stock Units covered by this Restricted Stock Unit Agreement
        that
        have become vested and nonforfeitable as soon as administratively practicable
        after the Vesting Date but in no event later than the end of the calendar
        year
        in which the Vesting Date occurs. 

       

      (b)    Notwithstanding
        paragraph (a)
        of this Section 6, if the Recipient terminates employment with the Company
        and
        all its Subsidiaries prior to the Vesting Date solely as a result of the
        Recipient’s death, termination of employment on or after “Early Retirement Age”
or “Normal Retirement Age,” or “Total Disability,” as defined in the Retirement
        Income Plan, then the Company shall deliver to the Recipient (or, if applicable,
        the Recipient’s Designated Beneficiary or legal representative) that number of
        shares of Company Stock as is equal to the number of Restricted Stock Units
        covered by this Restricted Stock Unit Agreement as soon as administratively
        practicable after the Recipient’s Separation from Service, but in no event later
        than the end of the calendar year in which such Separation from Service
        occurs.  The Recipient’s “Separation from Service” shall mean his
“separation from service,” within the meaning of Section 409A of the Code and
        Treas. Reg. Section 1.409A-1(h)(1), from the Company. 

       

      (c)    Notwithstanding
        anything in
        this Section 6 to the contrary, to the extent (i) the Recipient is entitled
        to settlement of Restricted Stock Units upon his Separation from Service
        pursuant to paragraph (b) of this Section 6; and (ii) at the time of his
        Separation from Service, the Recipient is a “specified employee” of the Company
        under Section 409A of the Code (a “Specified Employee”), then delivery of
        Company Stock and payment of any related dividend equivalents upon settlement
        of
        the Recipient’s Restricted Stock Units shall be made, 

       

       

      
        
          
          

        

        
          2

          
            

          

        

        
          
          

        

      

       

       

      without
        interest, upon the earlier of (i) the first
        business day following the expiration of six months following the Recipient’s
        Separation from Service; and (ii) the date of the Recipient’s death; provided,
        however, that such deferral shall be effected only if and to the extent required
        to avoid adverse tax treatment to the Recipient under Section 409A of the
        Code. 

       

      (d)    If
        the Recipient is (or is
        reasonably expected to be) a “covered employee” within the meaning of Section
        162(m) of the Code for the calendar year in which delivery of Company Stock
        or
        payment of dividend equivalents would ordinarily be made to the Recipient,
        the
        Company may delay delivery to the Recipient of that portion of the shares
        of
        Company Stock and/or dividend equivalents for which the Company reasonably
        believes that Section 162(m) of the Code will preclude the Company from taking
        a
        compensation expense deduction, until the Recipient’s Separation from
        Service.  Notwithstanding the foregoing, if the Recipient is a
        Specified Employee of the Company at the time of his Separation from Service,
        then such delayed delivery of Company Stock or payment of dividend equivalents
        shall be made on the first business day following the expiration of six months
        following the Recipient’s Separation from Service. 

       

      7.    No
        Rights
        as a Shareholder.  Until shares of Company Stock are issued, if
        at all, in satisfaction of the Company’s obligations under this Restricted Stock
        Unit Agreement, the Recipient shall have no rights as a
        shareholder. 

       

      8.    Notices.  Any
        notice required or permitted under this Restricted Stock Agreement shall
        be
        deemed given when delivered personally, or when deposited in a United States
        Post Office, postage prepaid, addressed, as appropriate, to the Recipient
        either
        at the Recipient’s address as last known by the Company or such other address as
        the Recipient may designate in writing to the Company. 

       

      9.    Securities
        Laws Requirements.  The Company shall not be obligated to
        transfer any shares of Company Common Stock issued in settlement of this
        Restricted Stock Unit grant from the Recipient to another party, if such
        transfer, in the opinion of counsel for the Company, would violate the
        Securities Act of 1933, as amended from time to time (or any other federal
        or
        state statutes having similar requirements as may be in effect at that
        time).  Further, the Company may require as a condition of transfer of
        any shares to the Recipient that the Recipient furnish a written representation
        that he or she is holding the shares for investment and not with a view to
        resale or distribution to the public. 

       

      10.    Protections
        Against Violations of Constituent Documents.  No purported
        sale, assignment, mortgage, hypothecation, transfer, pledge, encumbrance,
        gift,
        transfer in trust (voting or other) or other disposition of, or creation
        of a
        security interest in or lien on, any of the shares of Company Stock deliverable
        following the vesting of the Restricted Stock Units by any holder thereof
        in
        violation of the provisions of the Certificate of Incorporation or the By-Laws
        of the Company, shall be valid, and the Company will not transfer any of
        said
        shares of Company Stock on its books nor will the holder of any of said Company
        Stock be entitled to vote, nor will any dividends be paid thereon, unless
        and
        until there has been full compliance with said provisions to the satisfaction
        of
        the Company.  The foregoing restrictions are in addition to and not in
        lieu of any other remedies, legal or equitable, available to enforce said
        provisions. 

       

       

      
        
          
          

        

        
          3

          
            

          

        

        
          
          

        

      

       

       

      11.    Taxes.  The
        obligations of the Company under this Restricted Stock Unit Agreement shall
        be
        conditional on satisfaction of the Company’s legal tax withholding obligations
        and, unless the Recipient has made alternative arrangements satisfactory
        to the
        Company with respect to such tax withholding obligations, the Company will
        (1)
        withhold from the shares of Company Stock otherwise deliverable hereunder
        such
        number of shares as it determines is necessary to satisfy all applicable
        withholding tax obligations in respect of such shares, or (2) to the extent
        permitted by law, deduct any such taxes from any payment of any kind otherwise
        due to the Recipient by the Company. 

       

      12.    Failure
        to
        Enforce Not a Waiver.  The failure of the Company to enforce at any
        time any provision of this Restricted Stock Agreement shall in no way be
        construed to be a waiver of such provision or of any other provision
        hereof. 

       

      13.    Governing
        Law.  This Restricted Stock Unit Agreement shall be governed by and
        construed according to the laws of the State of New Jersey without regard
        to its
        principles of conflict of laws. 

       

      14.    Amendments. 
        Except as otherwise provided in Section 16, this Restricted Stock Unit Agreement
        may be amended or modified at any time only by an instrument in writing signed
        by each of the parties hereto. 

       

      15.    Survival
        of
        Terms.  This Restricted Stock Unit Agreement shall apply to and bind
        the Recipient and the Company and their respective permitted assignees and
        transferees, heirs, legatees, executors, administrators and legal
        successors. 

       

      16.    Agreement
        Not a Contract for Services.  Neither the grant of Restricted Stock
        Unit, the execution of this Restricted Stock Unit Agreement nor any other
        action
        taken pursuant to this Restricted Stock Unit Agreement shall constitute or
        be
        evidence of any agreement or understanding, express or implied, that the
        Recipient has a right to continue to provide services as an officer, director,
        employee or consultant of the Company for any period of time or at any specific
        rate of compensation. 

       

      17.    Severability. 
        If a provision of this Restricted Stock Unit Agreement is held invalid by
        a
        court of competent jurisdiction, the remaining provisions will nonetheless
        be
        enforceable according to their terms.  Further, if any provision is
        held to be over broad as written, that provision shall be amended to narrow
        its
        application to the extent necessary to make the provision enforceable according
        to applicable law and enforced as amended. 

       

      18.    Incorporation
        of Plan; Acknowledgment.  The Restricted Stock Unit Award is granted
        pursuant to the Plan, and the Restricted Stock Units and this Restricted
        Stock
        Unit Agreement are in all respects governed by the Plan and subject to all
        of
        the terms and provisions thereof, whether such terms and provisions are
        incorporated in this Restricted Stock Unit Agreement by reference or are
        expressly cited. By signing this Restricted Stock Agreement, the Recipient
        acknowledges having received and read a copy of the Plan. 

       

      
 

      
        
          
          

        

        
          4

          
            

          

        

        
          
          

        

      

       

       

      IN WITNESS
        WHEREOF, the parties hereto have executed and delivered this Restricted Stock
        Unit Agreement on the day and year first above written.

       

      
        
          	 	 	
                  SELECTIVE
                    INSURANCE GROUP, INC.

                  
                  

                
	 	 	
                  By: 
                    

                
	 	 	
                  Title:

                  
                  

                
	 	 	 	 
	 	 	
                  [EMPLOYEE]

                  
                  

                
	 	 	 
	 	 	 
	 	 	 	 
	 	 	
                  [CURRENT
                    DATE]

                  
                  

                

        

      

       

       

       

      5

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