**Item 7. Notice to: (Conditions 3 and 5)**

a) All Notices of Occurrence, Claim or Loss:

To:
Claims Department
Chubb Bermuda Insurance Ltd.
17 Woodbourne Avenue
Hamilton HM 08 Bermuda
Facsimile: 441-292-2456
E-mail: bermudaclaimsnotices@chubb.com

b) All other Notices:

To:
Underwriting Department
Chubb Bermuda Insurance Ltd.
17 Woodbourne Avenue
Hamilton HM 08 Bermuda
Facsimile: 441-296-7796

**Item 8.**
a) Gross Premium: USD 96,030.00 (For 100% Flat Annual)
b) Minimum Earned Premium: NONE
c) Commission: USD 2,400.75

**Item 9. The Company:**
Chubb Bermuda Insurance Ltd.
At the address stated in Item 7 of the Declarations Page

**Item 10. Policy Form:**
The Bermuda Shorts Form – BSF-03 (Ed. 03/14)

Endorsements:
1 to 4 at Policy Issuance

End. 001 001-04/14 Schedule of Excess Policy(ies) Endorsement
End. 002 004-04/14 Premium Payment Condition Endorsement
End. 003 008-04/14 Following Form Policy Issuance Endorsement
End. 004 048-12/15 Cancellation Endorsement

IN WITNESS WHEREOF, this Policy has been made, entered into and executed by the undersigned in Hamilton, Bermuda this 13th day of June, 2017.

By: **Authorized Representatives**

BSF-03