**Policy No.:** BM00025502LI11A

**Date:** JUNE 10, 2011

**THE BERMUDA SHORTS FORM**

**DECLARATIONS (cont'd)**

| Item 8. | a) Premium: | Gross: USD236,385 part of USD 630,360 |
| --- | --- | --- |
|  | 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 Endorsement II (XSBSF-026.01)
- 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 10TH day of JUNE, 2011.**

**By:** Vivienne Moniz

**Title:** ASSISTANT VICE PRESIDENT

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

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