**REINSURANCE LAYOFF SHEET**

- **ASSURED:** [Name]
- **POLICY NUMBER:** 9916310
- **EFF. DATE OF REINSURANCE:** 5/21/80
- **POLICY LIMIT:** $23,000,000
- **TYPE OF COVERAGE:** Excess Umbrella
- **UNDERLYING LAYER:** 2M+P
- **POLICY PREMIUM:** $1,983,250
- **POLICY PERIOD:** FROM: 5/1/80 TO: 5/21/81

**I PARTICIPATING/QUOTA SHARE**

| LIMITS: | PREMIUM: |
| --- | --- |
| 15m | $23,221 |

| REINSURER | REINSURANCE BROKER/DIRECT | PERCENT OF PARTICIP. | % OF CHANGE | TOTAL COMM. TO COMPANY | CLOSING CERT. NUMBER | CEDED PREMIUM ANNUAL | PRO-RATA |
| --- | --- | --- | --- | --- | --- | --- | --- |
| Nat Union | Flat Zac | 30% | 25% |  |  |  |  |
| Cologne Re | Flat Zac | 3% | 25% |  |  |  |  |
| PMA Re |  | 4.67 | 25% |  |  |  |  |
| Met Re |  | 33.33 | 25% |  |  |  |  |
| Mission Re |  | 3.33 | 25% |  |  |  |  |
| Security Re |  | 6.67 | 25% |  |  |  |  |
| Scandinia |  | 15% | 25% |  |  |  |  |

**II EXCESS OF LOSS OR SECTION II CASUALTY**

| LIMITS: | PREMIUM: |
| --- | --- |
|  |  |

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

**III**

| LIMITS: | PREMIUM: |
| --- | --- |
|  |  |

**AUTOMATIC**

| EXCESS TREATY REINSURANCE |
| --- |
| REMARKS: |
| BRANCH |
| UNDERWRITER | DATE |

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