**Policy No.:** BM00026949LI13A  
**Date:** May 28, 2013

**THE BERMUDA SHORTS FORM DECLARATIONS (cont'd)**

| Item 8. | a) Premium: |
| --- | --- |
|  | Gross: USD 236,385 part of USD 630,360 |
|  | Not: USD 236,385 part of USD 630,360 |
| b) Minimum Earned Premium: | 0% |
| 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 | Title |
| --- | --- |
| 1 | Schedule of Excess Policy (ies) |
| 2 | Several Liability Notice Endorsement |
| 3 | Following Form Bermuda Shorts Form Policy Amendatory Endorsement |
| 4 | Arbitration Endorsement |
| 5 | Choice of Law Endorsement (II) |
| 6 | Assistance and Co-operation Amendment Endorsement |
| 7 | Cancellation Amendment Endorsement - 90 Days |
| 8 | Premium Payment Condition Endorsement |
| 9 | Following Form Policy Issuance Endorsement |

**IN WITNESS WHEREOF,** this Policy has been made, entered into and executed by the undersigned in Hamilton, Bermuda on this 18th day of June, 2013.

By: **Authorized Representative**