Furnish the information required by items A to G if action is to be taken with respect to the election of directors; any bonus, profit sharing or other remuneration plan, contract or arrangement in which any director, nominee for election as a director, or officer of the insurer will participate; any pension or retirement plan in which any such person will participate; or the granting or extension to any such person of any options, warrants or rights to purchase any securities other than warrants or rights issued to security holders, as such, on a pro rata basis. If the solicitation is made on behalf of persons other than the issuer, the information required need be furnished only as to nominees of the persons making the solicitation and associates of the nominees.
(A) | (B) | (C) | (D) |
Name of individual or number of persons in group | Capacities in which served | Cash and cash equivalent forms of remuneration | Aggregate of contingent forms of remuneration |
(C1) | (C2) | ||
Salaries, fees, directors' fees, commissions, and bonuses | Securities or property, insurance benefits, reimbursement, or personal benefits |
Columns (C1), (C2) and (D) should contain with respect to each person or group of persons specified in item A, subitems (1) and (2) a dollar amount which reflects the total of all items of remuneration described in the heading to that column including those items set forth in the subparagraphs of that column.
COLUMN (C) | COLUMN (D) | |
Include all cash and cash equivalent forms of remuneration received during the fiscal year and all such amounts accrued during the fiscal year which, with reasonable certainty, will be distributed or vested in the future. | Include all contingent forms of remuneration the distribution, vesting, and measurement of which is subject to future events. Report only amounts relating to the latest fiscal year, not amounts accrued in previous periods. | |
COLUMN (C1) | COLUMN (C2) | |
Salaries, bonuses, fees, and commissions | Securities, property, insurance benefits or reimbursement, personal benefits (Perquisites) | |
1. All cash remuneration distributed or accrued in the form of salaries, commissions, bonuses and fees for services rendered. | 1. Spread between the acquisition price, if any, and fair market price of securities or property acquired under any contract, plan or arrangement. | 1. Amount expensed for financial reporting purposes representing nonvested contributions, payments, or accruals under any pension or retirement plans, annuities, employment contracts, deferred compensation plans including Internal Revenue Service qualified plans, unless the amount for the individual cannot be separated in which case a footnote is required indicating the percentage which contributions to the plan bear to participant's total remuneration. |
2. Compensation earned for services performed in the latest fiscal year even if it is deferred for future payment. | 2. Cost of any life insurance premiums, health insurance premiums and medical reimbursement plans. Premiums for nondiscriminatory plans generally available to all salaried employees are excluded. | 2. The amount expensed for financial reporting purposes under any incentive compensation plans (long-term income plans), such as stock appreciation rights, stock options, performance share plans, where payout is based on objective standards or stock value. |
In subsequent years, if the corporation credits compensation expense for financial reporting purposes as a result of a decline in the value of contingent compensation, Column D may be reduced by a corresponding amount. A footnote explaining such action should be included. | ||
3. Payments received in the latest fiscal year but earned in prior years which were deferred until the latest year, if such amounts were not shown in an earlier proxy statement or annual report to stockholders. | 3. Personal benefits (perquisites) not directly related to job performance, excluding benefits provided on a nondiscriminatory basis, valued on the basis of cost to the issuer of providing these benefits. | 3. The amount expensed for financial reporting purposes for any nonvested contribution payment or accrual to stock purchase plans, profit sharing, and thrift plans whether or not they are qualified under the Internal Revenue Code. |
a. If unreasonable effort or expense is required to determine the amounts of personal benefits, they may be omitted if their aggregate value does not exceed $10,000 for each officer. | ||
b. If the amount of personal benefits exceeds ten percent of the amount of total remuneration or $25,000, whichever is less, the amount and a brief description of the benefits must be disclosed in a footnote. | ||
4. Vested company contributions to thrift, profit sharing, pension, stock purchase and similar plans. |
Name | Name | Name | All Directors and Officers as a Group | |||
Title of securities | ||||||
Granted - .... to date: | ||||||
Number of shares | _____ | _____ | _____ | _____ | ||
Average per share option price | $_____ | $_____ | $_____ | $_____ | ||
Exercised - .... to date: | ||||||
Number of shares | _____ | _____ | _____ | _____ | ||
Aggregate option price of options exercised | $_____ | $_____ | $_____ | $_____ | ||
Aggregate market value of shares on date options exercised | $_____ | $_____ | $_____ | $_____ | ||
Sales - .... to date: | ||||||
Number of shares | _____ | _____ | _____ | _____ |
(Sales by directors and officers who exercised options during the month, day, and year to the date of the proxy material.)
Unexercised at ....: | ||||||
Number of shares | _____ | _____ | _____ | _____ | ||
Average per share option price | $_____ | $_____ | $_____ | $_____ |
In addition, during the period employees were granted options for ____ shares at an average price per share of $____.
Minn. R. agency 120, ch. 2715, SCHEDULE A; INFORMATION REQUIRED IN PROXY STATEMENT, pt. 2715.7770
Statutory Authority: MS s 60A.22