EXHIBIT 10.11
BAY CITIES BANK
ENDORSEMENT SPLIT DOLLAR PLAN
BENEFICIARY DESIGNATION AND LIMITED ASSIGNMENT OF RIGHTS
Owner: BAY CITIES BANK, and its successors and assigns (Employer/Bank)
Endorsee: XXXXXXX X. XXXXXX and his successors and assigns (Employee)
Insurer: XXXX XXXXXXX VARIABLE LIFE INSURANCE COMPANY
Policy No.: 58 961 001
Insured: XXXXXXX X. XXXXXX (Employee)
In consideration of Bay Cities Bank Endorsement Split Dollar Life Insurance
Agreement (the "Agreement") entered into between the above named Owner and
Endorsee, Owner and Endorsee agree as follows:
The above numbered Policy is subject to this Endorsement Split Dollar Plan
Beneficiary Designation and Limited Assignment of Rights (the "Endorsement
Plan") as referenced in the Agreement and specified herein, subject to all terms
and conditions of the Policy and to all liens, if any, which the Insurer may
have against the Policy.
I. PURPOSE:
This Endorsement Plan grants the Endorsee a right to name a
beneficiary of death proceeds, in an amount specified below,
and does not give the Endorsee any other rights.
II. BENEFICIARIES:
Endorsee's beneficiary designated for a fixed amount; Owner
designated for the remaining proceeds.
(a) The Endorsee's designated beneficiary(ies), shall be
entitled to payment of FIVE HUNDRED THOUSAND DOLLARS
($500,000.00).
(b) In the event that the cumulative net amount at risk
insurance portion of the proceeds is not sufficient
to fully cover the amount defined in Paragraph II(a)
above, the Endorsee's beneficiary(ies) shall only be
entitled to the remaining net amount at risk
insurance portion which does exist in the policy. The
net amount at risk insurance portion is the total
death benefit proceeds less the cash value of the
policy.
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(c) The Owner shall be entitled to the remainder of such
death benefit proceeds.
III. AGREEMENT:
The undersigned hereby agree that the Insurer may rely on the
Owner's written statement of the amount due to be paid to the
beneficiaries upon the death of the Insured. Upon payment of
the death proceeds based on such statement, the Insurer shall
be fully released under the Policy and the respective
beneficiaries shall indemnify the Insurer to that effect. If
the Insurer is made, or elects to become, a party to any
litigation concerning the proper apportionment of the net
death proceeds, the Insurer's litigation expenses, including
attorney fees, shall be deducted from the net death proceeds.
This Endorsement Plan shall be binding upon the parties and
their successors, heirs, assigns, devisees, personal
representatives and other legal representatives. The Insurer
will not be liable for any action it takes before this
Endorsement Plan is received and acknowledged at the Insurer's
Home Office. In the event of any conflict between this
Endorsement Plan and the terms in the Agreement, the Agreement
shall prevail.
IV. ENDORSEE'S DESIGNATION OF BENEFICIARY:
The Endorsee, subject to the rights of the Owner as stated
above and in the Agreement, designates the following as the
primary and contingent beneficiaries of the proceeds described
in Section II above. The beneficiaries designated by the
Endorsee are revocable and the identity of the Beneficiaries
may be changed upon Endorsee's signature alone.
Primary Beneficiary(ies) are:
FULL NAME RELATIONSHIP TO INSURED DATE OF BIRTH SOCIAL SECURITY
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If no primary beneficiary survives the Insured, CONTINGENT BENEFICIARY(IES) are:
FULL NAME RELATIONSHIP TO INSURED DATE OF BIRTH SOCIAL SECURITY
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If there is no living beneficiary at the death of the Insured, then the proceeds
described in Section II will be paid to Endorsee or Endorsee's estate.
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Signed this ________ day of _______________, 2002
If signing for an entity, the undersigned represents that s/he has the authority
to bind the entity.
"Employer"
BAY CITIES BANK
By:__________________________________
Its:_________________________________
P.O. Box 21027
Tampa, FL 33622-1027
"Employee"
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XXXXXXX X. XXXXXX
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Home Address
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Filed at the Home Office of the Insurer this ______ day of __________________,
2002. Xxxx Xxxxxxx Variable Life Insurance Company assumes no responsibility for
the validity of the contents of this document.
By:
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Authorized Officer
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