**POLICY NUMBER:**
XEX-12673420

**POLICY TYPE:**
BLANKET EXCESS LIABILITY POLICY (FOLLOWING FORM)

**DECLARATIONS:**

* **INSURED:**
  - Name: [Insured's Name]
  - Address: [Insured's Address]

* **POLICY PERIOD:**
  - Effective Date: 5/21/77
  - Expiration Date: 5/21/78

* **ITEM 1: LIMIT OF LIABILITY**
  - Each Occurrence: $10,000,000
  - Aggregate: $10,000,000

* **ITEM 2: UNDERLYING INSURANCE LIMIT OF LIABILITY**
  - Each Occurrence: $40,000,000
  - Aggregate: $40,000,000

* **ITEM 3: PREMIUM BASIS**
  - Flat Charge: $14,520

* **ITEM 4: ADVANCE PREMIUMS**
  - Annual Minimum Premium: $14,520
  - Not Less Than: $3,000

* **ITEM 5: SCHEDULE OF UNDERLYING INSURANCE**
  - See Endorsement

**IN THE EVENT OF CANCELLATION BY THE NAMED INSURED, THE COMPANY HAS THE POLICY MINIMUM DUE.**

**INSURING AGREEMENTS:**

1. **Coverage:**
   - The Company shall be liable for the Insured's ultimate net liability under the insurance afforded under the Blanket Excess Liability or "Umbrella" policies specified in Item 1 of the Declarations.
   - The Company shall not be liable for any loss or damage to property under this policy and underlying policies.

2. **Limit of Liability:**
   - The Company shall be liable only for the limit of liability stated in the Declarations in excess of the applicable limits of the underlying insurance policy or policies as stated in the Declarations of this policy.
   - The limit of liability shall be the total limit of the Company's liability for all damages sustained as the result of one occurrence, provided that in the event of reduction or exhaustion of the applicable aggregate limit of liability, the Company's liability is reduced by recovery of losses paid thereunder on account of occurrences during this policy period.

**DEFINITIONS:**

* **Ultimate Net Loss:** Means all sums actually paid, or which the Insured is legally obligated to pay, on account of any claim or demand made against the Insured arising out of an occurrence covered by this policy, after proper deduction of all recoveries or settlements.

**CONDITIONS:**

1. **Maintenance of Primary Insurance:**
   - The Insured warrants, and it is a condition of this policy, that at the inception of this policy, the insurance afforded by the underlying policies of insurance (applicable to the Insured) is in full force and effect.

**COUNTERSIGNATURE DATE:**
6/14/77 eh

**AUTHORIZED SIGNATURE:**
[Signature]
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This document appears to be a detailed insurance policy form, specifically a blanket excess liability policy. It outlines the terms, conditions, and coverage details for the insured party.