**Policy No.:** BM00029768LI16A  
**Date:** July 18, 2016

**THE BERMUDA SHORTS FORM DECLARATIONS (cont'd)**

**Item 9. The Company:**
- XL Insurance (Bermuda) Ltd
- O'Hara House
- One Bermudiana Road
- P.O. Box HM 2245
- Hamilton HM JX
- Bermuda
- Facsimile: (441) 292 1566

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

**Endorsements at Policy Issuance:**
1. Schedule of Excess Policy(ies)
2. Several Liability Notice Endorsement
3. Premium Payment Condition Endorsement
4. Cancellation Amendment Endorsement - 90 Days
5. Economic or Trade Sanctions Endorsement

**IN WITNESS WHEREOF, this Policy has been made, entered into and executed by the undersigned in Hamilton, Bermuda this 18th day of July, 2016**

**By:**
Arketa Tucker

**Title:** Vice President