**Policy No.:** BM00028732LI15A  
**Date:** July 21, 2015

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

**b) All Other Notices:**

- **Attn:** XL Insurance (Bermuda) Ltd
- **O'Hara House**
- **One Bermudiana Road**
- **Hamilton, HM 08, Bermuda**
- **P.O. Box HM 2245**
- **Hamilton HM JX**
- **Bermuda**
- **Telephone:** (441) 292-8515
- **Facsimile:** (441) 292 1566

**Item 8.**
- **a) Premium:** 
  - **Gross:** USD 213,006
  - **Net:** USD 213,006
- **b) Minimum Earned Premium:** 0%
- **c) Commission:** 0%

**Item 9. The Company:**
- **XL Insurance (Bermuda) Ltd**
- **O'Hara 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 – 03 (Ed. 03/14)**

**Endorsements at Policy Issuance:**

| End. No. | Title |
|----------|-------|
| 1        | Schedule of Excess Policy(ies) |
| 2        | Follow Form Bermuda Shorts Form Policy Amendatory Endorsement |
| 3        | Several Liability Notice Endorsement |
| 4        | Premium Payment Condition Endorsement |
| 5        | Cancellation Amendment Endorsement - 90 Days |

**IN WITNESS WHEREOF,** this Policy has been made, entered into and executed by the undersigned in Hamilton, Bermuda this 21st day of July, 2015.

**By:**  
**Shelle' Hendrickson**  
**Title:** Assistant Vice President  
**XL XS-BSF-03 (Ed. 03/14)**

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