Exhibit 10.11
SURVIVOR INCOME BENEFIT AGREEMENT
THIS AGREEMENT, entered into this ____ day of February, 2005, is made by
and between Peoples State Bank, a state-chartered commercial bank with its
principal office located in Wausau, Wisconsin (hereafter the "Bank") and
___________________________________ (hereafter the "Executive").
INTRODUCTION
To encourage the Executive to remain an employee of the Bank, the Bank is
willing to provide survivorship benefits to the Executive's beneficiary if the
Executive dies prior to terminating employment or dies while receiving
disability benefits subsequent to terminating employment with the Bank as a
result of a disability. The Bank will pay the benefits from its general
assets, but only so long as one of its general assets is a life insurance
policy on the Executive's life.
AGREEMENT
The Executive and the Bank agree as follows:
ARTICLE 1
SURVIVORSHIP BENEFIT
1.1 Death Prior to Executive Attaining Age Sixty-seven (67) and prior to
Termination of Employment. If the Executive dies before otherwise
terminating employment with the Bank prior to the Executive attaining
age sixty-seven (67), the Bank shall pay the Executive's beneficiary
a Survivor Income Benefit amount equal to Two Hundred percent (200%)
of the Executive's annual base salary as of the date of the
Executive's death. The amount of Survivorship Benefit so determined
herein shall be paid to the Executive's beneficiary within sixty (60)
days following the date of the Executive's death.
1.2 Death Prior to Executive Attaining Age Sixty-seven (67) and
Subsequent to the Disability of the Executive. If the Executive's
employment is terminated due to Disability and the Executive
thereafter dies prior to attaining age sixty-seven (67), the Bank
shall pay the Executive's beneficiary a Survivorship Benefit amount
equal to Two Hundred percent (200%) of the Executive's annual base
salary that was in effect at the time of the Executive's termination
of employment due to Disability. Disability means (i) the inability
of the Executive 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 more than twelve (12) months, or (ii) the
receipt of income replacement benefits for a period of more than
three (3) months under a Bank-sponsored accident and health plan
covering the Executive due to a medically determinable physical or
mental impairment which is expected to result in death or is expected
to last for a continuous period of more than twelve (12) months. The
Executive must submit proof to the Bank of the carrier's or Social
Security Administration's determination upon the request of the Bank.
The amount of Survivor Income Benefit so determined herein shall be
paid to the Executive's beneficiary within sixty (60) days following
the date of the Executive's death.
1.3 Death of the Executive Subsequent to the Executive Attaining Age
Sixty-seven (67). No benefits shall be payable under this Agreement if the
Executive dies after attaining age sixty-seven (67).
1.4 Suicide or Misstatement. The Bank shall not pay any benefit under
this Agreement if the Executive commits suicide within two (2) years after the
date of this Agreement. In addition, the Bank shall not pay any benefit under
this Agreement if the Executive has made any material misstatement of fact on
any application for life insurance owned by the Bank on the Executive's life
that results in the Bank being unable to collect the total death proceeds from
such policies.
ARTICLE 2
BENEFICIARIES
2.1 Beneficiary Designations. The Executive shall designate a
beneficiary by filing a written designation with the Bank. The Executive may
revoke or modify the designation at any time by filing a new designation.
However, designations will only be effective if signed by the Executive and
accepted by the Bank during the Executive's lifetime. 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. If the Executive dies
without a valid beneficiary designation, all payments shall be made to the
Executive's surviving spouse, if any, and if none, to the Executive's surviving
children and the descendants of any deceased child by right of representation,
and if no children or descendants survive, to the Executive's estate.
2.2 Facility of Payments. If a benefit is payable to a minor, to a
person declared incompetent, or to a person incapable of handling the
disposition of his or her property, the Bank may pay 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
incompetency, minority or guardianship as it may deem appropriate prior to
distribution of the benefit. Such distribution shall completely discharge the
Bank from all liability with respect to such benefit.
ARTICLE 3
CLAIMS AND REVIEW PROCEDURES
3.1 Claims Procedure. An 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:
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3.1.1 Initiation - Written Claim. The claimant initiates a claim
by submitting to the Plan Administrator a written claim for the benefits.
3.1.2 Timing of Plan Administrator Response. The Plan
Administrator shall respond to such claimant within ninety (90) days
after receiving the claim. If the Plan Administrator determines that
special circumstances require additional time for processing the claim,
the Plan Administrator can extend the response period by an additional
ninety (90) days by notifying the claimant in writing, prior to the end
of the initial ninety (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 Plan Administrator expects to
render its decision. If there is an extension, a decision on the claim
shall be made as soon as possible, but not later than one hundred eighty
(180) days after receipt by the Plan Administrator of your initial claim
for benefits.
3.1.3 Notice of Decision. If the Plan Administrator denies part or
all of the claim, the Plan Administrator shall notify the claimant in
writing of such denial. The Plan Administrator 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.
3.2 Review Procedure. If the Plan Administrator denies part or all of
the claim, the claimant shall have the opportunity for a full and fair review
by the Plan Administrator of the denial, as follows:
3.2.1 Initiation - Written Request. To initiate the claim denial
review, the claimant, within sixty (60) days after receiving the Plan
Administrator's notice of denial, must file with the Plan Administrator a
written request for review.
3.2.2 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 Plan
Administrator shall also provide the claimant, upon request and free of
charge, reasonable access to, and copies of, all documents,
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records and other information relevant (as defined in applicable ERISA
regulations) to the claimant's claim for benefits.
3.2.3 Considerations on Review. In considering the review, the
Plan Administrator 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.
3.2.4 Timing of Plan Administrator Response. The Plan
Administrator shall respond in writing to such claimant within sixty (60)
days after receiving the request for review. If the Plan Administrator
determines that special circumstances require additional time for
processing the claim, the Plan Administrator can extend the response
period by an additional sixty (60) days by notifying the claimant in
writing, prior to the end of the initial sixty (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 Plan Administrator
expects to render its decision. This extension may only be made where
there are special circumstances which are communicated to you in writing
within the initial sixty (60) day period. If there is an extension, a
decision on your appeal shall be made as soon as possible, but not later
than one hundred twenty (120) days after receipt by the Plan
Administrator of your initial claim for review.
3.2.5 Notice of Decision. The Plan Administrator shall notify the
claimant in writing of its decision on review. The Plan Administrator
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).
ARTICLE 4
AMENDMENTS AND TERMINATION
4.1 Amendments and Termination This Agreement may be amended or
terminated only by a written agreement signed by the Bank and the Executive.
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ARTICLE 5
MISCELLANEOUS
5.1 Exclusive Agreement / Binding Effect. This Agreement is the entire
agreement between the Bank and the Executive, written or oral, related to the
Bank's obligation to pay any death benefits to the Executive's beneficiaries or
survivors. This Agreement supercedes all prior agreements, understanding and
negotiations. This Agreement shall bind the Executive and the Bank, and their
beneficiaries, survivors, executors, administrators and transferees.
5.2 No Guaranty of Employment. This Agreement is not an employment
policy or contract. It does not give the Executive the right to remain an
employee 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 employee
nor interfere with the Executive's right to terminate employment at any time.
5.3 Applicable Law. The Agreement and all rights hereunder shall be
governed by the laws of the State of Wisconsin, except to the extent preempted
by the laws of the United States of America.
5.4 Unfunded Plan. The beneficiary is a general unsecured creditor of
the Bank for the payment of benefits under this Agreement. The
benefits represent the mere promise by the Bank to pay such benefits.
The beneficiary's rights to such benefits are not subject in any
manner to anticipation, alienation, sale, transfer, assignment,
pledge, encumbrance, attachment, or garnishment by creditors. Any
insurance on the Executive's life is a general asset of the Bank to
which the Executive and the designated beneficiary have no preferred
or secured claim.
5.5 Full Obligation. Notwithstanding any provision to the contrary, when
the Bank has paid a Survivorship benefit under any section of the
Agreement, the Bank has completed its obligation to the Executive.
5.6 Named Fiduciary. The Bank shall be the named fiduciary and plan
administrator under this Agreement. The named fiduciary may delegate
to others certain aspects of the management and operation
responsibilities of the plan including the employment of advisors and
the delegation of ministerial duties to qualified individuals.
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IN WITNESS WHEREOF, a duly authorized officer of the Bank and the
Executive have signed this Agreement as of the day first noted above.
BANK:
PEOPLES STATE BANK
By:_____________________________________
Its:_____________________________________
EXECUTIVE:
______________________________________
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BENEFICIARY DESIGNATION FORM
I designate the following as Beneficiary of benefits under the Survivor Income
Benefit Agreement with the Peoples State Bank and payable following my death:
PRIMARY:
Name Address Relationship
CONTINGENT:
Name Address Relationship
NOTE: TO NAME A TRUST AS BENEFICIARY, PLEASE PROVIDE THE NAME OF THE
TRUSTEE(S) AND THE EXACT NAME AND DATE OF THE TRUST AGREEMENT.
I understand that I may change these Beneficiary designations by delivering a
new written designation to the Plan Administrator. 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: _______
SPOUSAL CONSENT (REQUIRED IF SPOUSE NOT NAMED BENEFICIARY):
I consent to the Beneficiary designations above, and acknowledge that if I am
named Beneficiary and our marriage is subsequently dissolved, the designation
naming me beneficiary will be automatically revoked.
SPOUSE NAME: _______________________________
SIGNATURE: _______________________________DATE: ______________
Received by the Plan Administrator this ________ day of ___________________,
20___.
By: _________________________________
Title: _________________________________
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