**REINSURANCE PAYOFF SHEET**

- **ASSURED:** [Blank]
- **TYPE OF COVERAGE:** FOR CASUALTY USE ONLY
- **POLICY NUMBER:** [Blank]
- **UNDERLYING LAYER:** [Blank]
- **EFF. DATE OF REINSURANCE:** [Blank]
- **POLICY PREMIUM:** $1,983,250
- **POLICY LIMIT:** $6,000,000
- **POLICY PERIOD:** FROM: [Blank] TO: [Blank]

**I PARTICIPATING/QUOTA SHARE LIMITS:**

| REINSURER | REINSURANCE BROKER/DIRECT | PERCENT OF PARTICIP. | % OF CHANGE | TOTAL COMM. TO COMPANY | CLOSING CERT. NUMBER | CEDED PREMIUM ANNUAL | PRO-RATA |
|-----------|--------------------------|----------------------|-------------|------------------------|-----------------------|-----------------------|-----------|
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |

**TREATY NO.:** [Blank]

**II EXCESS OF LOSS OR SECTION II CASUALTY LIMITS:** $5M

| REINSURER | REINSURANCE BROKER/DIRECT | PERCENT OF PARTICIP. | % OF CHANGE | TOTAL COMM. TO COMPANY | CLOSING CERT. NUMBER | CEDED PREMIUM ANNUAL | PRO-RATA |
|-----------|--------------------------|----------------------|-------------|------------------------|-----------------------|-----------------------|-----------|
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |
| [Blank]   | [Blank]                  | [Blank]              | [Blank]     | [Blank]                | [Blank]               | [Blank]               | [Blank]    |

**III LIMITS:** [Blank]

**AUTOMATIC EXCESS TREATY REINSURANCE**

**REMARKS:** [Blank]
**BRANCH:** [Blank]
**UNDERWRITER:** [Blank]
**DATE:** [Blank]

**24120 7778**