**Policy No.:** BM00024832LI10A

**Date:** JULY 1, 2010

**THE BERMUDA SHORTS FORM**

**DECLARATIONS (cont'd)**

**Item 8.**
- **a) Premium:**
  - Gross: USD 236,385 part of USD 630,360
  - Net: USD 236,385
- **b) Minimum Earned Premium:** 35%
- **c) Commission:** 0%

**Item 9.** The Company:
- XL Insurance (Bermuda) Ltd
- XL 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 – 02 (Ed. 07/09)

**Endorsements at Policy Issuance:**
- End. No. 1. Schedule of Excess Policies (XSBSF-001.01)
- End. No. 2. Several Liability Notice Endorsement (XSBSF-010.01)
- End. No. 3. Arbitration Endorsement (XSBSF-003.01)
- End. No. 4. Choice of Law IV (XSBSF-021.01)
- End. No. 5. Premium Payment Condition Endorsement (XSBSF-007.01)

**IN WITNESS WHEREOF,** this Policy has been made, entered into and executed by the undersigned in Hamilton, Bermuda on this 1st day of JULY, 2010.

**By:** Vivienne Moniz  
**Title:** Assistant Vice President

XL XS-BSF-02 (Ed. 07/09)  
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