# Declaration

## Item 7. Notice to:
a) All Notices of Occurrence, Claim or Loss:
- To: The Company as shown in the attached Individual Security Details;
- And: Aon Bermuda Ltd.
  - 30 Woodbourne Ave.
  - Pembroke, Bermuda
  - HM08
  - Email: debbie.brown@aon.com and media.williams@aon.com

b) All other Notices:
- Via: Aon Bermuda Ltd.
  - 30 Woodbourne Ave.
  - Pembroke, Bermuda
  - HM08
- To: The Company

## Item 8.
a) Premium: USD 97,375
b) Minimum Earned Premium: 35%
c) Commission: Net

## Item 9.
The Company:
- Name: As per Individual Security Details
- Address: As per Individual Security Details

## Item 10.
Policy Form: The Bermuda Shorts Form – 03 (Ed. 03/14)
Endorsements:
- Number One – Schedule of Underlying Policy(ies)
- Number Two – Premium Payment Condition
- Number Three – Following Form Policy Issuance
Any Additional Endorsements to those shown above will be shown on Individual Security Details (if applicable)

# Page | 2
# Declarations
# 5/20/2019