# DECLARATIONS, cont’d

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

- **a) All Notices of Occurrence, Claim or Loss:**
  - To:
    - Chartis Excess Limited
    - 29 Richmond Road
    - Pembroke HM08 Bermuda

- **b) All other Notices:**
  - To:
    - Aon (Bermuda) Ltd.
    - Aon House
    - 30 Woodbourne Avenue
    - Pembroke HM08 Bermuda

**Item 8.**
- **a) Premium:** US$ 245,000 (for 100% Flat Annual)
- **b) Minimum Earned Premium:** US$ 85,750

**Item 9. The Company:**
- Chartis Excess Limited
- At the address stated at the top of the Declarations Page

**Item 10. Policy Form: Endorsements**
- The Bermuda Shorts Form – 103271(11/09)
- 1 - 6 at Policy Issuance

**Authorized Representative**

**Page 1 of 2**

**CHARTIS EXCESS LIMITED**
- Head Office: 30 North Wall Quay, Dublin 1 Ireland
- Branch Office, Bermuda - 29 Richmond Road, Pembroke, HM08
- Branch Office, U.K. - 58 Fenchurch Street, London, EC3M 4AB
- Chartis Excess Limited is incorporated and registered in The Republic of Ireland, Registration No. 279452, and is regulated by The Central Bank of Ireland.

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