**ALLIED WORLD ASSURANCE COMPANY**

Fax No.(441) 296-3428

Item 8.
a) Premium: USD69,125
b) Minimum Earned Premium: USD24,194
c) Commission:

Item 9. The Company: Allied World Assurance Company, AG

Item 10. Policy Form: The Bermuda Shorts Form – 03 (Ed. 07/13)
Endorsements 1 - 4 at Policy Issuance

Authorized Representative

Date of Issuance: July 11, 2014
ACBSF-03 (07/13)

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