Declarations - Travelers Insurance

ITEM 1ITEM 2ITEM 3IDENTITY FRAUD EXPENSE REIMBURSEMENTDECLARATIONSTravelers Casualty and Surety Company of AmericaHartford, Connecticut(A Stock Insurance Company, herein called the Company)INSURANCE REPRESENTATIVE:D/B/A:Principal Address:POLICY PERIOD:POLICY NO. XXXXXXXXXXInception Date: Expiration Date: 12:01 A.M. standard time both dates at the Principal Address stated in ITEM 1.ALL NOTICES OF CLAIM OR LOSS MUST BE SENT TO THE COMPANY BY EMAIL,FACSIMILE, OR MAIL AS SET FORTH BELOW:Email: FAX: Travelers Bond & Financial ProductsAttn: Claim DepartmentITEM 4 COVERAGE INCLUDED AS OF THE INCEPTION DATE IN ITEM 2:ITEM 5SpecimenIdentity Fraud Expense ReimbursementIDENTITY FRAUD EXPENSE REIMBURSEMENTLimit of Insurance: $ per Insured Person for each IdentityFraudRetention: $ per Insured Person for each IdentityFraudIDF-2001 Ed. 01-09 Printed in U.S.A. Page 1 of 2©2009 The Travelers Companies, Inc. All Rights Reserved

ITEM 6PREMIUM FOR THE POLICY PERIOD:$ Policy Premium$ Annual Installment PremiumITEM 7 FORMS AND ENDORSEMENTS ATTACHED AT ISSUANCE:THE DECLARATIONS, THE APPLICATION, THE IDENTITY FRAUD EXPENSEREIMBURSEMENT TERMS AND CONDITIONS, AND ANY ENDORSEMENTS ATTACHEDTHERETO, CONSTITUTE THE ENTIRE AGREEMENT BETWEEN THE COMPANY, THEINSURANCE REPRESENTATIVE, AND THE INSURED PERSON._____________________________Countersigned By(where applicable)IN WITNESS WHEREOF, the Company has caused this policy to be signed by its authorized officers.Executive Vice PresidentCorporate SecretarySpecimenIDF-2001 Ed. 01-09 Printed in U.S.A. Page 2 of 2©2009 The Travelers Companies, Inc. All Rights Reserved