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EXHIBIT 4.2
LOGO
Enrollment/Purchase Form
SELECTIVE INSURANCE GROUP, INC.
STOCK PURCHASE PLAN FOR INDEPENDENT INSURANCE AGENTS
Please complete:
Agency Name:____________________________________________________________________
Primary Agency Code:____________________________________________________________
Agency's Federal Tax Identification Number:_____________________________________
Please indicate the desired payment method(s) by marking the appropriate
block(s) below. (NOTE: 1, 2 OR ALL 3 PAYMENT METHODS MAY BE SELECTED.)
On behalf of the above named Agency, I hereby elect to enroll in the Selective
Insurance Group, Inc.'s Stock Purchase plan for Independent Insurance Agents. I
understand a maximum total contribution of $30,000 in the aggregate for all
Participants associated with a single Agent and from all payment methods applies
for each Quarterly Purchase. I further understand that Common Stock of the
Company will be purchased in accordance with the Prospectus, a copy of which has
been give to me.
_____. 1) DIRECT BILL COMMISSION PAYMENT METHOD (SUBMIT 15 DAYS PRIOR TO A
SCHEDULED PURCHASE DATE). I request that $___________ or ________% of my direct
bill commission be withheld from each commission statement, effective with the
next scheduled commission statement date, for the next scheduled Quarterly
Purchase and for future Quarterly Purchases, subject to a maximum total
contribution of $30,000 in the aggregate for all Participants associated with a
single Agent.
_____. 2) LUMP SUM PAYMENT METHOD (SUBMIT 15 DAYS PRIOR TO A SCHEDULED PURCHASE
DATE). I will make a lump sum payment (not less than $100, subject to a maximum
total contribution of $30,000 in the aggregate for all Participants associated
with a single Agent). A check is enclosed with this form for the total amount of
the payment.
_____. 3) PROFIT SHARING DEDUCTION PAYMENT METHOD (SUBMIT BY JANUARY 15 OF EACH
YEAR) I request that $_________ or ____________% of my distribution from the
Selective Insurance Profit Sharing Plan for Agents, be withheld from my profit
sharing distribution to purchase shares during the next quarterly purchase,
subject to a maximum total contribution of $30,000 in the aggregate for all
Participants associated with a single Agent.
Please check the applicable block(s):
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___ New Participant
___ Change of Direct Bill Commission Withholding Percentage for next Purchase Date.
___ Addition or deletion of Payment Option for next Purchase Date.
___ Change of Participant for whom stock should be registered (see page 2)
___ Change of Agency/Participant Address (see page 2)
___ Lump Sum Payment
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I would like the shares purchased to be registered in the names of the following
individuals/entities according to the specifications set forth below (ONLY
NECESSARY IF NEW PARTICIPANT, LUMP SUM PAYMENTS OR CHANGES NEED TO BE MADE TO
PRIOR REGISTRATION INFORMATION)
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PLEASE LIST AS MANY PARTICIPANTS (ENTITIES/INDIVIDUALS) AS YOU DESIRE ALONG WITH
THE CORRESPONDING INFORMATION. PLEASE USE ADDITIONAL SHEETS IF MORE SPACE IS
REQUIRED:
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FULL LEGAL NAME AND SOCIAL IF COMMISSION SIGNATURE OF PARTICIPANT FIRST TIME
FULL MAILING ADDRESS SECURITY DEDUCTION PURCHASE
OF INDIVIDUAL/ENTITY NUMBER OR PAYMENT METHOD (YES OR NO)
FOR WHOM STOCK TAXPAYER OR PROFIT SHARING
SHOULD BE REGISTERED ID. NUMBER DEDUCTIONS
PAYMENT METHOD,
PERCENTAGE OF
TOTAL PURCHASE
(WHOLE NUMBERS
TOTALING 100%).
IF LUMP SUM
PURCHASE, TOTAL
DOLLAR AMOUNT
ENCLOSED.
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2.
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3.
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UNDER PENALTIES OF PERJURY, I CERTIFY THAT THE TAX IDENTIFICATION / SOCIAL
SECURITY NUMBER SHOWN ABOVE FOR EACH PARTICIPANT IS CORRECT.
I hereby represent and warrant to Selective that (a) a copy of the most recent
Prospectus covering the Plan has been delivered to the person listed above, and
(b) the funds remitted with this form or withheld in accordance with the
instructions above in payment of the purchase represent all funds contributed by
the person listed above in payment of such purchase. If this Purchase Form is
not received by Selective at least 15 days prior to the next scheduled purchase
date, I understand such purchase will not be made until the next succeeding
scheduled purchase date.
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Allocations of shares to the above participants and in the above percentages
will remain in effect for future purchase dates until changed by filing another
purchase form with Selective Insurance Group, Inc.
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<S> <C>
DATE:
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(SIGNATURE AND TITLE OF AGENCY PRINCIPAL/PARTNER/EXECUTIVE OFFICER)
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