# Lexington Insurance Company

**Wilmington, Delaware**
**(A Stock Insurance Company)**

**Administrative Offices:** 100 Summer Street, Boston, Massachusetts

## Declarations - Following Form Excess Liability Policy

### Section I - Excess Insurance
- **Policy Period:**
  - From: 12:01 a.m. Standard Time at the Address of the Insured stated herein.
- **Coverage:**
- **Limits of Liability:**
- **Premium:**
  - Minimum Premium:
  - Audit Period:
- **Rating Base:**
- **Rate:**

### Section II - Underlying Insurance
- **Underlying Policy:**
  - **Policy No.:**
  - **Policy Limit:**
  - **Policy Period:**
- **Total limits of all underlying insurance including the underlying policy in excess of which this policy applies:**

### Endorsements Made Part of this Policy:

**Countersigned On:** At Boston, Massachusetts 02110
**By:** Authorized Representative

**Policy No.:** 5528820
**Renewal of No.:** [Blank]
**Named Insured:** [Blank]
**Address:** [Blank]