Exhibit 4.6
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Enrollment/Purchase Form
For Purchase Date to Occur _________________
Agency Name: ___________________________________________________________________
Primary Agency Code: ___________________________________________________________
Agency's Federal Tax Identification Number: ____________________________________
Agency Enrollment
Method of payment:
Please indicate the method of payment the Agency listed above desires to use to
purchase shares on the first quarterly purchase date of 2001:
. Incentive Commission/Profit Sharing Payment Method: Amount Deducted: $______
-------------------------------------------------- Percentage Deducted:___%
The undersigned Agency hereby authorizes Vesta Insurance Group, Inc. and its
affiliates to deduct the amount, or the percentage, indicated above from the
incentive commission to which the agency would otherwise be entitled and to
apply such amount toward the purchase of shares for the Agency's account in
accordance with the Plan prospectus.
. Cash Contribution Method: Amount Contributed: $_____
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The undersigned Agency hereby delivers a check, payable to Vesta Insurance
Group, Inc., in the amount indicated above for the purchase of shares for the
Agency's account in accordance with the Plan prospectus.
Dividend Reinvestment (check one):
. Full Dividend Reinvestment: Reinvest dividends on all shares including
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certificated and book-entry plan shares. ________________
. Cash Dividends: Pay dividends on all shares including certificated shares
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and book-entry plan shares. ________________
If neither option is indicated, the account will be enrolled as Full Dividend
Reinvestment
Certification:
On behalf of the Agency listed above, I hereby represent and warrant to Vesta
that (a) a copy of the most recent Plan prospectus covering the Plan has been
delivered to the Agency listed above, and (b) the funds remitted with this form
or deducted in accordance with the instructions above in payment of the purchase
represent all funds contributed by the Agency listed above in payment of such
purchase. If this Purchase Form is not received by Vesta 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.
By:
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Name:
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Position:
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If agency is authorizing Additional "Non-Agency" Participants (up to ten),
please indicate the number of additional participant information sheets that
follow:
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Additional "non-agency" participant information (Photocopy page if necessary)
As an eligible agency for the calendar year 2001, the undersigned agency also
authorizes the Plan administrator to establish accounts for the following
individuals/entities (up to ten) according to the specifications set forth
below:
Name of Participant:
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Name of Affiliated Agency:
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Social Security/Tax ID #:
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Address:
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Telephone Number:
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Amount of Cash Contributed: $
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Dividend Reinvestment Option:
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(indicate either (i) Dividend Reinvestment or (ii)
Cash Dividends; if no option is indicated, the
account will be enrolled as Dividend Reinvestment)
UNDER PENALTIES OF PERJURY, I CERTIFY THAT THE TAX IDENTIFICATION / SOCIAL
SECURITY NUMBER SHOWN ABOVE IS CORRECT.
I hereby represent and warrant to Vesta that (a) a copy of the most recent Plan
prospectus covering the Plan has been delivered to the participant named above,
and (b) the funds remitted with this form represent all funds contributed by the
participant named above in payment of such purchase. If this Purchase Form is
not received by Vesta 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.
By:
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Name:
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Position with Entity:
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