EXHIBIT 4.1
EXHIBIT 4.1
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DONEGAL GROUP INC.
2001 AGENCY STOCK PURCHASE PLAN
SUBSCRIPTION AGREEMENT
Instruction: Please indicate the desired payment method(s) by marking the
appropriate block(s) below. (Note: 1, 2 or all 3 payment methods
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may be elected up to an aggregate of $12,000 per Subscription
Period.)
On behalf of (the
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"Agency"), (insert agency number), the Agency hereby elects
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to enroll in the Donegal Group Inc. 2001 Agency Stock Purchase Plan (the
"Plan"). The Agency understands that a maximum total contribution of $12,000
from all payment methods applies for each Subscription Period. The Agency
further understands that, subject to the terms of the Plan, shares of Class A
Common Stock of the Company will be purchased in accordance with the Prospectus,
a copy of which has been delivered to the Agency.
[ ] DIRECT XXXX COMMISSION PAYMENT METHOD (BY THE END OF THE APPLICABLE
ENROLLMENT PERIOD)
The Agency requests that % (not less than 1% and not more than 10%
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of direct xxxx commissions subject to a maximum of $12,000 per Subscription
Period) of the Agency's direct xxxx commission be withheld from each
commission statement during the next six-month Subscription Period and for
future Subscription Periods).
[ ] LUMP-SUM PAYMENT METHOD (BY THE END OF THE APPLICABLE SUBSCRIPTION PERIOD)
The Agency will make a lump-sum payment (not less than $1,000 and not
greater than $12,000 per Subscription Period less amounts paid under the
direct xxxx commission payment method and/or the contingent commission
payment method). Enclosed is a check in the amount of $ or, if
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no check is enclosed, a Lump-Sum Contribution Supplemental Transmittal
Statement, in the form provided to the Agency, will be submitted with the
Agency's payment by September 30 or March 31 of the respective Subscription
Period.
[ ] CONTINGENT COMMISSION PAYMENT METHOD (BY THE END OF THE ENROLLMENT PERIOD
APPLICABLE TO THE OCTOBER 1 THROUGH MARCH 31 SUBSCRIPTION PERIOD)
The Agency requests that % (subject to a maximum dollar amount not
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greater than $12,000 per Subscription Period less amounts paid under the
direct xxxx commission payment method and/or the lump-sum payment method)
be deducted from the Agency's contingent commission, if any, payable to the
Agency under the applicable agency contingent plan for the purchase of
stock during the next October 1 to March 31 Subscription Period in which
the contingent commission, if any, is paid. [COMPLETE REVERSE SIDE ALSO]
PLEASE CHECK THE APPLICABLE BLOCK:
[ ] Continuing Participant from Donegal Group Inc. 1996 Agency Stock
Purchase Plan
[ ] New Participant
[ ] Change of Direct Xxxx Commission Withholding Percentage
[ ] Withdrawal from the Plan at the end of the current Subscription
Period
[ ] Withdrawal from the Plan immediately and receive all funds withheld
for the current Subscription Period
[ ] Addition or deletion of Payment Option for current Subscription
Period
Federal Tax ID No.:
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(Agency Name)
By: Date:
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Title:
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NOTE:
Registration of stock will be in the Agency's name, unless written instructions
are received pursuant to the permitted designations set forth in the Plan and
the Prospectus.
This form should be submitted to Donegal Group, Inc., 0000 Xxxxx Xxxx, Xxxxxxxx,
Xxxxxxxxxxxx 00000, Attention: Xxxxx X. Xxxxxxx, Senior Vice President, Chief
Financial Officer and Secretary.
DONEGAL GROUP INC.
2001 AGENCY STOCK PURCHASE PLAN
LUMP-SUM CONTRIBUTION
SUPPLEMENTAL TRANSMITTAL STATEMENT
The undersigned Agency has previously submitted, or is concurrently
submitting, to Donegal Group Inc. (the "Company") a Subscription Agreement in
connection with the Agency's participation in the Company's 2001 Agency Stock
Purchase Plan (the "Plan"). The Agency hereby elects to make a lump-sum
contribution under the Plan. For the current Subscription Period, enclosed is
$ to be used to purchase the Company's Class A Common Stock in
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accordance with the terms of the Plan.
Please Complete:
Federal Tax ID No.:
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(Agency Name)
By: Date:
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Title:
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INSTRUCTIONS:
This form should be sent to Donegal Group Inc., 0000 Xxxxx Xxxx, Xxxxxxxx,
Xxxxxxxxxxxx 00000, Attention: Xxxxx X. Xxxxxxx, Senior Vice President, Chief
Financial Officer and Secretary, along with a Subscription Agreement if not
previously submitted for the Subscription Period and your check and be received
prior to September 30 or March 31 of the respective Subscription Period. The
dollar amount set forth above must be at least $1,000 and may not exceed, when
added to the amounts paid under the direct xxxx commission payment method and/or
the contingent commission payment method for the current Subscription Period, an
aggregate of $12,000.