FORM-CUBL- BSF01 (02/09)

POLICY NO.: IBM-064/CUBLBSF01-09
NEW BUSINESS:

Which in turn is in excess of various insurances and/or retentions as more fully set forth in the Followed Policy

DECLARATIONS, cont’d

Item 7 Notice to:
(Conditions 3 & 5)
a) All Notices of Occurrences; Claims or Loss
To:
Canopius Underwriting Bermuda Limited
Atlantic House
11 Par-La-Ville Road
Hamilton, HM11 Bermuda
Facsimile: (441) 294-9459
E-Mail: claims@canopius.bm

b) All other Notices:
To:
Aon (Bermuda) Ltd.
Cumberland House
One Victoria Street
Hamilton, Bermuda HM 11

Item 8 a) Premium
b) Minimum Earned Premium
c) Commission
USD81,250 (For 100% Flat Annual)
USD28,438
0%

Item 9 The Company:
Canopius Underwriting Bermuda Limited
At the address stated in Item 7 (a)

Item 10 Policy Form:
Endorsements
The Bermuda Shorts Form – 01 (Ed. 02/09)
1 – 4 at Policy Issuance

**Signature**

Jeremy J. Wright, VP
Canopius Underwriting Bermuda Limited
Underwriting on behalf of
Syndicate 4444 at Lloyd's