# Berkley Custom Insurance Services, LLC

License #0101622  
(a W.R. Berkley Company)

| New York Changes - Cancellation and Nonrenewal | CX 02 33 06 10 |
|----------------------------------------------|----------------|
| New York Changes-Transfer of Duties When a Limit of Insurance | CX 01 15 01 11 |
| Common Policy Conditions | IL 00 17 11 98 |
| Commercial Excess Liability Coverage Form | CX 00 01 04 13 |
| Signature Page | IL DS 77 00 BNLS 04 10 |
| U.S. Treasury Department's Office of Foreign Assets Control | IL P 001 01 04 |

## Special Conditions:
- Cancellation term is 30 days. Term is 10 days for non-payment of premium.
- In compliance with the Terrorism Risk Insurance Program Reauthorization Act of 2015, terrorism coverage under the Act can be included for an additional premium. The completed and signed Policyholder Disclosure Notice of Terrorism Insurance Coverage must be returned at the time of binding.
- Premium is due 45 days from the Effective Date of coverage.
- The Quote is valid through 05/21/2019.

## Subjectivities:
- Please provide us with a copy of the Underlying Policies, including the Carrier, Effective Date, Expiration Date, Policy Number, Limits and Premium, Required Within 60 Days of Binding.
- Signed and Dated TRIA Letter, Required Prior to Binding.
- Please provide us with a copy of the Underlying Carrier Binders, Required Prior to Binding.

## Comments & Modifications:
- Please read the foregoing carefully as the terms and conditions may not correspond with the coverage specifications outlined in your submission. Thanks for your order.