**FORM-CUBL- BSF02 (07/09)**

**POLICY NO.: IBM-200/CUBLBSF02-11**

**RENEWAL OF: IBM-141/CUBLBSF02-10**

**DECLARATIONS, cont'd**

**Item 7 Notice to:** (Conditions 3 & 5)

a) All Notices of Occurrences; Claims or Loss

To:
Canopius Underwriting Bermuda Limited
Atlantic House
11 Par-La-Ville Road
Hamilton, HM11 Bermuda
Facsimile: (441) 294-9459
E-Mail: claims@canopius.bm

b) All other Notices:

To:
Aon (Bermuda) Ltd
30 Woodbourne Avenue
Pembroke HM 08
Bermuda

**Item 8**
a) Premium USD78,795.00 (For 100% Flat Annual)
b) Minimum Earned Premium USD27,578.25
c) Commission Net

**Item 9 The Company:**
Canopius Underwriting Bermuda Limited
At the address stated in Item 7 (a)

**Item 10 Policy Form: Endorsements**
The Bermuda Shorts Form – 02 (Ed. 07/09)
1 – 8 at Policy Issuance

**Jeremy J. Wright, VP**