Document:

Exhibit
10.2

 

1999
EQUITY PLAN

FOR EMPLOYEES OF

ALLIANCE IMAGING, INC. AND SUBSIDIARIES

 

RESTRICTED STOCK UNIT AWARD
GRANT NOTICE AND

RESTRICTED STOCK UNIT AWARD AGREEMENT

(DIRECTORS)

 

Alliance Imaging, Inc.,
a Delaware corporation, (the “Company”), pursuant to the 1999 Equity Plan for
Employees of Alliance Imaging, Inc. and Subsidiaries, as amended from time
to time (the “Plan”),
hereby grants to the individual listed below (“Participant”), an award of restricted
stock units (“Restricted Stock Units” or “RSUs”) with respect to the number of
shares of Stock set forth below (the “Shares”). 
This award of Restricted Stock Units is subject to all of the terms and
conditions as set forth herein and in the Restricted Stock Unit Award Agreement
attached hereto as Exhibit A (the “Restricted Stock Unit Agreement”) and
the Plan, each of which are incorporated herein by reference.  Unless otherwise defined herein, the terms
defined in the Plan shall have the same defined meanings in this Grant Notice
and the Restricted Stock Unit Agreement.

 

	
  Participant:

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Grant Date:

  	
   

  	
                                     ,
  2007

  
	
   

  	
   

  	
   

  
	
  Vesting

  Commencement Date:

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Total Number of RSUs:

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Vesting Schedule:

  	
   

  	
  One
  hundred percent (100%) of the Restricted Stock Units shall vest on the first
  anniversary of the Vesting Commencement Date, subject to Participant’s
  continued service with the Company or its Subsidiaries through such date.

  

 

By Participant’s signature
and the Company’s signature below, Participant agrees to be bound by the terms
and conditions of the Plan, the Restricted Stock Unit Agreement and this Grant
Notice.  Participant has reviewed the Restricted
Stock Unit Agreement, the Plan and this Grant Notice in their entirety, has had
an opportunity to obtain the advice of counsel prior to executing this Grant
Notice and fully understands all provisions of this Grant Notice, the Restricted
Stock Unit Agreement and the Plan. 
Participant hereby agrees to accept as binding, conclusive and final all
decisions or interpretations of the Company upon any questions arising under
the Plan, this Grant Notice or the Restricted Stock Unit Agreement.

 

	
  ALLIANCE IMAGING, INC.:

  	
   

  	
  PARTICIPANT:

  
	
  By:

  	
   

  	
   

  	
  By:

  	
   

  
	
  Print
  Name:

  	
   

  	
   

  	
  Print
  Name:

  	
   

  
	
  Title:

  	
   

  	
   

  	
   

  	
   

  
	
  Address:

  	
   

  	
   

  	
  Address:

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  

 

 

EXHIBIT A

TO RESTRICTED STOCK UNIT AWARD GRANT NOTICE

ALLIANCE IMAGING, INC. RESTRICTED STOCK UNIT AWARD AGREEMENT

(DIRECTORS)

 

Pursuant to the Restricted
Stock Unit Award Grant Notice (the “Grant Notice”)
to which this Restricted Stock Unit Award Agreement (the “Agreement”)
is attached, Alliance Imaging, Inc., a Delaware corporation (the “Company”) has granted to Participant
the right to receive the number of Restricted Stock Units under the 1999 Equity
Plan for Employees of Alliance Imaging, Inc. and Subsidiaries, as amended
from time to time (the “Plan”), as
set forth in the Grant Notice.  The Award
is subject to the terms and conditions of the Plan which are incorporated
herein by reference.  In the event of any
inconsistency between the Plan and this Agreement, the terms of the Plan shall
control.

 

1.             Grant of the RSUs.  As set forth in the Grant Notice, the Company
hereby grants the Participant RSUs in exchange for past and future services to
the Company subject to all the terms and conditions in this Agreement, the Grant
Notice and the Plan.  However, no Shares
shall be issued to the Participant until the time set forth in Section 4.  Prior to actual payment of any Shares, such RSUs
will represent an unsecured obligation of the Company, payable only from the
general assets of the Company.

 

2.             Definitions.  All capitalized terms used in this Agreement
without definition shall have the meanings ascribed to them in the Plan and the
Grant Notice.

 

3.             Acceleration of Vesting.  Notwithstanding anything herein to the
contrary, Participant’s RSUs shall become fully vested immediately prior to the
consummation of the merger or consolidation of the Company into another
corporation, the exchange of all or substantially all of the assets of the
Company for the securities of another corporation, the acquisition by another
corporation of 80% or more of the Company’s then outstanding shares of voting
stock or the recapitalization, reclassification, liquidation or dissolution of
the Company.

 

4.             Issuance of Stock.

 

(a)           Timing of
Distribution.  Shares shall
be issued to the Participant with respect to vested RSUs as soon as
administratively practicable after such RSUs vest.

 

(b)           General.  Shares issued pursuant to this Section 4
shall be issued (either in book-entry form or otherwise) to the Participant or
the Participant’s beneficiaries, as the case may be.  No fractional Shares shall be issued under
this Agreement.  Unless otherwise
determined by the Board of Directors, in the event Participant ceases to be an
Employee, consultant to the Company or member of the Board of Directors, the RSUs
shall cease vesting immediately upon such cessation of service and any unvested
RSUs awarded by this Agreement shall be forfeited.

 

5.             Taxes.  Notwithstanding anything to the contrary in this
Agreement, the Company shall be entitled to require payment to the Company or
any of its Subsidiaries any sums required by federal, state or local tax law to
be withheld with respect to the issuance of the Restricted Stock Units, the
distribution of shares of Stock with respect thereto, or any other taxable
event related to the Restricted Stock Units. 
The Company may permit the Participant to make such payment in one or
more of the forms specified below:

 

(a)           by
cash or check made payable to the Company;

 

(b)           by
the deduction of such amount from other compensation payable to Participant;

 

 

(c)           in
the sole discretion of the Company, by requesting that the Company withhold a
net number of vested Shares otherwise issuable having a then current Fair
Market Value not exceeding the amount necessary to satisfy the withholding
obligation of the Company and its Subsidiaries based on the minimum applicable
statutory withholding rates for federal, state, local and foreign income tax
and payroll tax purposes; or

 

(d)           in
any combination of the foregoing.

 

In the event
Participant fails to provide timely payment of all sums required by the Company
pursuant to this Section 5, the Company shall have the right and option,
but not obligation, to treat such failure as an election by Participant to
satisfy all or any portion of his or her required payment obligation by means
of requesting the Company to withhold vested Shares otherwise issuable in
accordance with clause (c) above. 
The Company shall not be obligated to deliver any new certificate
representing Shares issuable with respect to the Restricted Stock Units to
Participant or Participant’s legal representative unless and until Participant
or Participant’s legal representative shall have paid or otherwise satisfied in
full the amount of all federal, state, local and foreign taxes applicable to
the taxable income of Participant resulting from the grant of the Restricted
Stock Units, the distribution of the Shares issuable with respect thereto, or
any other taxable event related to the Restricted Stock Units.

 

6.             Rights as
Stockholder.  Neither the
Participant nor any person claiming under or through the Participant will have
any of the rights or privileges of a stockholder of the Company in respect of
any Shares deliverable hereunder unless and until certificates representing
such Shares (which may be in book entry form) will have been issued and
recorded on the records of the Company or its transfer agents or registrars,
and delivered to the Participant (including through electronic delivery to a
brokerage account).  After such issuance,
recordation and delivery, the Participant will have all the rights of a
stockholder of the Company with respect to voting such Shares and receipt of
dividends and distributions on such Shares.

 

7.             Conditions to Issuance of
Certificates. 
Notwithstanding any other provision of this Agreement, the Company shall
not be required to issue or deliver any certificate or certificates for any
Shares prior to the fulfillment of all of the following conditions:  (A) the admission of the Shares to
listing on all stock exchanges on which such Shares are then listed, (B) the
completion of any registration or other qualification of the Shares under any
state or federal law or under rulings or regulations of the Securities and
Exchange Commission or other governmental regulatory body, which the Company
shall, in its sole and absolute discretion, deem necessary and advisable, (C) the
obtaining of any approval or other clearance from any state or federal
governmental agency that the Company shall, in its absolute discretion,
determine to be necessary or advisable and (D) the lapse of any such
reasonable period of time following the date the RSUs vest as the Company may
from time to time establish for reasons of administrative convenience.

 

8.             Award Not Transferable.  This grant and the rights and privileges
conferred hereby will not be transferred, assigned, pledged or hypothecated in
any way (whether by operation of law or otherwise) and will not be subject to
sale under execution, attachment or similar process.  Upon any attempt to transfer, assign, pledge,
hypothecate or otherwise dispose of this grant, or any right or privilege
conferred hereby, or upon any attempted sale under any execution, attachment or
similar process, this grant and the rights and privileges conferred hereby
immediately will become null and void.

 

9.             Not a Contract of Service.  Nothing in this Agreement or in the Plan
shall confer upon the Participant any right to continue to serve the Company or
any of its subsidiaries.

 

 

10.           Governing Law.   The laws of the State of Delaware shall
govern the interpretation, validity, administration, enforcement and
performance of the terms of this Agreement regardless of the law that might be
applied under principles of conflicts of laws.

 

11.           Conformity to Securities
Laws.  The Participant acknowledges
that the Plan and this Agreement are intended to conform to the extent
necessary with all provisions of the Securities Act of 1933, as amended, and
the Exchange Act, and any and all regulations and rules promulgated
thereunder by the Securities and Exchange Commission, including without
limitation Rule 16b-3 under the Exchange Act.  Notwithstanding anything herein to the
contrary, the Plan shall be administered, and the Awards are granted, only in
such a manner as to conform to such laws, rules and regulations.  To the extent permitted by applicable law,
the Plan and this Agreement shall be deemed amended to the extent necessary to
conform to such laws, rules and regulations.

 

12.           Amendment, Suspension and
Termination.  To the
extent permitted by the Plan, this Agreement may be wholly or partially amended
or otherwise modified, suspended or terminated at any time or from time to time
by the Committee or the Board of Directors,
provided, that, except as may otherwise be provided by the Plan, no
amendment, modification, suspension or termination of this Agreement shall
adversely effect the Award in any material way without the prior written
consent of the Participant.

 

13.           Notices.  Notices required or permitted hereunder shall
be given in writing and shall be deemed effectively given upon personal
delivery or upon deposit in the United States mail by certified mail, with
postage and fees prepaid, addressed to the Participant to his address shown in
the Company records, and to the Company at its principal executive office.

 

14.           Successors and Assigns.  The Company may assign any of its rights
under this Agreement to single or multiple assignees, and this Agreement shall
inure to the benefit of the successors and assigns of the Company.  Subject to the restrictions on transfer
herein set forth, this Agreement shall be binding upon Participant and his or
her heirs, executors, administrators, successors and assigns.

 

15.           Compliance in Form and
Operation.  This
Agreement and the Restricted Stock Units are intended to comply with Section 409A
of the Code and the Treasury Regulations thereunder and shall be interpreted in
a manner consistent with that intention.Exhibit 10.3
 
ALLIANCE IMAGING, INC.
 
DIRECTORS’ DEFERRED COMPENSATION PLAN
 
 

As
Amended and Restated Effective December 14, 2007

 

 

TABLE
OF CONTENTS

 

	
   

  	
  Page

  
	
   

  	
   

  
	
  ARTICLE I. DEFINITIONS

  	
  1

  
	
   

  	
   

  
	
  ARTICLE II. ELECTION TO
  DEFER

  	
  2

  
	
   

  	
   

  
	
  ARTICLE III. DEFERRED
  COMPENSATION ACCOUNTS

  	
  3

  
	
   

  	
   

  
	
  ARTICLE IV. PAYMENT OF
  DEFERRED COMPENSATION

  	
  4

  
	
   

  	
   

  
	
  ARTICLE V. ADMINISTRATION

  	
  5

  
	
   

  	
   

  
	
  ARTICLE VI. AMENDMENT OF
  PLAN

  	
  5

  
	
   

  	
   

  
	
  APPENDIX A

  	
  6

  

 

i

 

ARTICLE I.

DEFINITIONS

 

1.1           “Affiliate” shall mean, with respect to the Company any
entity directly or indirectly controlling, controlled by, or under common
control with the Company.

 

1.2           “Board” shall mean the Board of Directors of the Company.

 

1.3           “Cash Account” shall mean the account created by the Company
pursuant to Article III of this Plan in accordance with an election by a
Director to receive deferred cash compensation under Article II hereof.

 

1.4           “Change of Control” shall mean the any one of the following:

 

i)      Any person
or persons acting as a group (within the meaning of Treas. Reg.
§1.409A-3(i)(5)(vi)(D)), acquires (or has acquired within the 12 month period
ending on the date of the last acquisition by such person or persons) directly
or indirectly, fifty percent (50%) or more of the voting power of the then
outstanding securities of the Company entitled to vote for the election of the
Company’s directors; provided that this Section 1.5(i) shall not
apply with respect to any acquisition of securities by any employee benefit
plan (within the meaning of Section 3(3) of the Employee Retirement
Income Security Act of 1974, as amended) maintained by the Company or an Affiliate
of the Company;

 

ii)     Any person
or persons acting as a group (within the meaning of Treas. Reg.
§1.409A-3(i)(5)(v)(B)), acquires ownership (including any previously owned
securities) of more than fifty percent (50%) of either (i) the voting
power value of the then outstanding securities of the Company entitled to vote
for the election of the Company’s directors or (ii) the fair market value
of the Company; provided that this Section 1.5(ii) shall not apply
with respect to any acquisition of securities by any employee benefit plan
(within the meaning of Section 3(3) of the Employee Retirement Income
Security Act of 1974, as amended) maintained by an Affiliate of the Company; or

 

iii)    A sale of
substantially all of the Company’s assets.

 

Provided, that the transaction or event described in
subsection (i), (ii), or (iii) constitutes a “change in control event,” as
defined in Treas. Reg. §1.409A-3(i)(5).

 

1.5           “Common Stock” shall mean the common stock of the Company,
par value $.01.

 

1.6           “Company” means Alliance Imaging, Inc.

 

1.7           “Director” shall mean a member of the Board who is not an
employee of the Company or any of its subsidiaries.

 

1

 

1.8           “Disability” means that the Director is unable to engage in
any substantial gainful activity by reason of any medically determinable
physical or mental impairment that can be expected to result in death or can be
expected to last for a continuous period of not less than twelve months.  For purposes of this Plan, a Director shall
be deemed to have a Disability if determined to be totally disabled by the
Social Security Administration.

 

1.9           “Fees” shall mean amounts earned for serving as a member of
the Board, including any committees of the Board.

 

1.10         “Person” shall mean an individual, partnership, corporation,
business trust, joint stock company, trust, unincorporated association, joint
venture, governmental authority or other entity of whatever nature.

 

1.11         “Phantom Share” shall mean a notional amount credited to the
Stock Account of a Director, which is equivalent to the value of one share of
Common Stock, determined in accordance with the terms of this Plan.

 

1.12         “Plan” shall mean this Directors’ Deferred Compensation Plan
as it may be amended from time to time.

 

1.13         “Separation from Service” means a termination of service with
the Company as a Director, as determined by the Board in accordance with
Treasury Regulation Section 1.409A-1(h).

 

1.14         “Stock Account” shall mean the account created by the Company
pursuant to Article III of this Plan in accordance with an election by a
Director to receive stock-based compensation under Article II hereof.

 

1.15         “Stock Value” shall mean, per share, for any given day the
closing price of the Company’s Common Stock as reported on the exchange upon
which such Common Stock is listed on such day or, if the closing price is not
available for the Common Stock on a date in question, then the next preceding
practicable date for which such closing price is available.

 

1.16         “Year” shall mean calendar year.

 

ARTICLE II.

ELECTION TO DEFER

 

2.1           A Director may elect, on or before December 31 of any
Year, to defer payment of all or a specified part of all Fees earned during the
Year following such election and in any succeeding Years (until the Director
ceases to be a Director).  Any person who
shall become a Director during any Year, and who was not a Director of the
Company on the preceding December 31, may elect, no later than seven (7) days
after the Director’s term begins, to defer payment of all or a specified part
of such Fees payable during the remainder of such Year and for any succeeding
Years.  Any Fees deferred 

 

2

 

pursuant to this Paragraph shall be
paid to the Director at the time(s) and in the manner specified in Article IV
hereof, as designated by the Director.

 

2.2           The election to participate in the Plan and manner of payment
shall be designated by submitting a letter in the form attached hereto as
Appendix A to the Secretary of the Company.

 

2.3           The election shall continue from Year to Year unless the
Director terminates it by written request delivered to the Secretary of the
Company prior to the commencement of the Year for which the termination is
first effective.

 

ARTICLE III.

DEFERRED COMPENSATION ACCOUNTS

 

3.1           The Company shall maintain separate memorandum accounts for
the Fees deferred by each Director.

 

3.2           The Company shall credit, on the date Fees would otherwise
become payable, to the Cash Account of each Director the deferred portion of
any Fees due the Director as to which an election to defer such Fees into the
Cash Account has been made.

 

3.3           On the first day of each quarter, the Company shall credit
the Cash Account of each Director with interest calculated on the basis of the
balance in such account on the first day of each month of the preceding quarter
at a rate equal to the three month $US LIBOR rate plus 225 basis points as in
effect from time to time.

 

3.4           The Company shall credit, on the date Fees would otherwise
become payable, the Stock Account of each Director with the number of Phantom
Shares that is equal to the quotient of (a) the deferred portion of any
Fees due to the Director as to which an election to defer such Fees into the
Stock Account has been made, DIVIDED by (b) the Stock Value. For purposes
of this Section 3.4, the Stock Value shall be determined on the date Fees
would otherwise have been paid.

 

3.5           The Company shall credit, on the date that any dividends are
paid with respect to Common Stock, the Stock Account of each Director who has
elected to defer Fees with the number of Phantom Shares that is equal to the
quotient of (a) the cash dividends payable on the number of shares of
Common Stock represented in each Director’s Stock Account, DIVIDED by (b) the
Stock Value on such dividend payment date.  If adjustments are made to the outstanding
shares of Common Stock as a result of split-ups, recapitalizations, mergers,
consolidations and other business combinations, an appropriate adjustment also
will be made in the number of Phantom Shares credited to the Director’s Stock
Account.

 

3.6           For purposes of this Plan, the value of each Phantom Share
shall be computed to three decimal places.

 

3.7           Fees deferred in the form of cash (and the interest payable
thereon) shall be held in the general assets of the Company and no separate
fund or trust shall be 

 

3

 

created or moneys set aside on
account of the Cash Account.  Further,
the Company shall not be required to acquire, reserve, segregate, or otherwise
set aside shares of its Common Stock for the payment of its obligations, if
any, with respect to the Stock Account, but shall make available as and when
required a sufficient number of shares of its Common Stock to meet the needs of
the Plan.

 

3.8           Nothing contained herein shall be deemed to create a trust of
any kind or any fiduciary relationship.  To
the extent that any person acquires a right to receive payments from the
Company under the Plan, such right shall be no greater than the right of any
unsecured general creditor of the Company.

 

3.9           The right to receive Common Stock at a later date shall not
entitle any person to rights of a stockholder with respect to such Common Stock
unless and until shares of Common Stock have been issued to such person
pursuant to Article IV hereof.

 

ARTICLE IV.

PAYMENT OF DEFERRED COMPENSATION

 

4.1           Amounts contained in a Director’s Cash Account and/or Stock
Account shall be distributed as the Director’s election (made pursuant to Section 2.2)
shall provide and the payment shall occur not later than thirty days following
the first day of the month next following the event that causes the
distribution pursuant to the Director’s election (made pursuant to Section 2.2).
 Amounts credited to a Director’s Stock
Account shall be paid, as the Director’s election shall provide, in shares of
Common Stock or in cash (in an amount equal to the product of (a) the
number of full Phantom Shares reflected as being held in the Director’s Stock
Account and (b) the then Stock Value) to the Director upon distribution.  If paid in Common Stock, a cash payment shall
be made in respect of any fractional shares of Common Stock, with such cash
payment being valued using the Stock Value on the date of settlement of the
Director’s Cash and Stock Accounts.  Any
share of Common Stock issued to a Director shall contain such restrictive legends
limiting the transferability of such shares as the Company’s counsel shall
advise.

 

4.2           Each Director shall have the right to designate a beneficiary
to succeed to his or her right to receive payments hereunder in the event of
death.  Any designated beneficiary shall
receive payments in the same manner as the Director if he or she had lived.  In case of a failure of designation or the
death of a designated beneficiary without a designated successor, the balance
of the amounts contained in the Director’s Cash Account and/or Stock Account
shall be paid, in accordance with Section 4.1, to the Director’s or former
Director’s estate no later than the end of the Year in which he or she dies.  No designation of beneficiary or change in
beneficiary shall be valid unless it is in writing signed by the Director and
filed with the Secretary of the Company.

 

4.3           Notwithstanding the foregoing, in the event of a Change of Control,
a Director shall become entitled to a full distribution of the Director’s Cash
Account and/or Stock Account, payable in a lump sum not later than 30 days following
the Change in Control.  In such event,
with respect to the Director’s Stock Account, the “Stock Value” shall mean the
price per share paid in cash to, or the value of any consideration received 

 

4

 

by, each holder of the Common Stock
in the transaction resulting in the Change of Control.

 

4.4           Notwithstanding any provision to the contrary in the Plan, if
a Director has elected to receive a distribution under the Plan at the time of
such Director’s Separation from Service and he or she is deemed by the Company
to be a “specified employee” for purposes of Section 409A(a)(2)(B)(i) of
the Code, to the extent delayed distribution of any portion of his or her
payments under the Plan to which he or she is entitled is required in order to
avoid a prohibited distribution under Section 409A(a)(2)(B)(i) of the
Code, such portion of such Director payments shall not be made before to the
earlier of (a) the expiration of the six-month period measured from the
date of his or her Separation from Service or (b) the date of his or her
death.  Upon the expiration of the
applicable Code Section 409A(a)(2)(B)(i) period, amounts deferred
pursuant to this Section 4.4 shall be distributed.

 

ARTICLE V.

ADMINISTRATION

 

5.1           The Company shall administer the Plan at its expense.  All decisions made by the Company with respect
to issues hereunder shall be final and binding on all parties. The Plan is
intended to comply with Section 409A of the Internal Revenue Code and
shall be administered and interpreted in accordance with such Section 409A
and related Treasury guidance and Regulations.

 

5.2           Except to the extent required by law, the right of any
Director or any beneficiary to any benefit or to any payment hereunder shall
not be subject in any manner to attachment or other legal process for the debts
of such Director or beneficiary, and any such benefit or payment shall not be
subject to alienation, sale, transfer, assignment or encumbrance.

 

ARTICLE VI.

AMENDMENT OF PLAN

 

6.1           The Plan may be amended, suspended or terminated in whole or
in part from time to time by the Board except that no amendment, suspension, or
termination shall apply to the payment to any Director or beneficiary of a
deceased Director of any amounts previously credited to a Director’s Cash
Account and/or Stock Account.

 

5

 

APPENDIX A
 
Date
 

Corporate
Secretary

Alliance
Imaging, Inc.

1900
S. State College Blvd., Suite 600

Anaheim,
CA 92806

 

Dear
Mr.                                 :

 

Pursuant to the Alliance Imaging, Inc.
Directors’ Deferred Compensation Plan, as amended to date (the “Plan”), I
hereby elect to defer receipt of all or a portion of the amounts I earn for
serving as a member of the Board, including any committees of the Board (“Fees”)
payable on or after January 1, 2008 and for succeeding calendar years in
accordance with the percentages indicated below.

 

I elect to have my Fees credited as follows
(fill in appropriate percentages for options a, b and c, below):

 

(a)                 %
of the aggregate Fees shall be credited to my Cash Account as defined in the
Plan;

 

(b)                 %
of the aggregate Fees shall be credited to my Stock Account as defined in the
Plan;

 

(c)                 %
of the aggregate Fees shall not be deferred but shall be paid directly to me
and/or the following person(s) or entity(ies) in the following percentages
as they accrue:

 

                %

 

                %

 

                %

 

Further,
I elect to receive the payments pursuant to the Plan (check method desired,
below):

 

              
in one lump sum

 

              
in             
equal annual installments

 

In
addition, I elect to receive the payments of the balance credited to my Stock
Account (check method desired, below) in the form of:

 

              
cash

 

              
stock

 

 

Lastly,
I hereby elect to begin receiving my payments under the Plan upon the earlier
of (check one or more):

 

                  The
date I incur a Separation from Service (as defined in the Plan).

 

                  The
date I experience a Disability (as defined in the Plan).

 

                                      ,
         (insert month, day and year)

 

In the event of my death prior to receipt of all or any balance of such fees and interest or dividends thereon so accumulated, I designate                                                    as my beneficiary to receive the funds so accumulated.
 
 

	Very truly yours,

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