Declarations - Travelers Insurance

Travelers Casualty and Surety Company of AmericaHartford, Connecticut(A Stock Insurance Company, herein called the Company)FIDUCIARY LIABILITYDECLARATIONSPOLICY NO. XXXXXXXXXXTHE LIABILITY COVERAGES ARE WRITTEN ON A CLAIMS-MADE BASIS. THE LIABILITY COVERAGES COVERONLY CLAIMS FIRST MADE AGAINST INSUREDS DURING THE POLICY PERIOD. THE LIMIT OF LIABILITYAVAILABLE TO PAY SETTLEMENTS OR JUDGMENTS WILL BE REDUCED BY DEFENSE EXPENSES, ANDDEFENSE EXPENSES WILL BE APPLIED AGAINST THE RETENTION. THE COMPANY HAS NO DUTY TODEFEND ANY CLAIM UNLESS DUTY-TO-DEFEND COVERAGE HAS BEEN SPECIFICALLY PROVIDED HEREIN.ITEM 1ITEM 2ITEM 3NAMED INSURED:D/B/A:Principal Address:POLICY PERIOD:Inception 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, ORMAIL AS SET FORTH BELOW:Email: FAX: Travelers Bond & Financial ProductsAttn: Claim DepartmentITEM 4 COVERAGE INCLUDED AS OF THE INCEPTION DATE IN ITEM 2:Fiduciary LiabilitySpecimenFRI-2001 Ed. 01-09 Printed in U.S.A. Page 1 of 3©2009 The Travelers Companies, Inc. All Rights Reserved

ITEM 5 Only those coverage features marked “ Applicable” are included in this policy.ITEM 6ITEM 7ITEM 8FIDUCIARY LIABILITYLimit of Liability: $ for all ClaimsSettlement Program Limit of Liability $for each Settlement Program Notice,which amount is included within, and notin addition to, any applicable limit of liabilityHIPAA Limit of Liability $ which amount is included within, and notin addition to, any applicable limit ofliabilityAdditional DefenseCoverage: Applicable Not ApplicableAdditional DefenseLimit of Liability: $ for all ClaimsRetention: $ for each Claim under Insuring Agreement APrior and PendingProceeding Date:Continuity Date:$PREMIUM FOR THE POLICY PERIOD:$ Policy Premium$ Annual Installment PremiumTYPE OF LIABILITY COVERAGE:ReimbursementDuty-to-DefendOnly the type of liability coverage marked “for each Settlement Program Notice under InsuringAgreement B” is included in this policy.LIABILITY COVERAGE EXTENDED REPORTING PERIOD:SpecimenAdditional Premium Percentage: %Additional Months:(If exercised in accordance with section III. CONDITIONS, O. EXTENDED REPORTING PERIOD of theLiability Coverage Terms and Conditions)FRI-2001 Ed. 01-09 Printed in U.S.A. Page 2 of 3©2009 The Travelers Companies, Inc. All Rights Reserved

ITEM 9LIABILITY COVERAGE RUN-OFF EXTENDED REPORTING PERIOD:ITEM 10ITEM 11Additional Premium Percentage: %Additional Months:(If exercised in accordance with section III. CONDITIONS, K. CHANGE OF CONTROL of the LiabilityCoverage Terms and Conditions)ANNUAL REINSTATEMENT OF THE LIABILITY COVERAGE LIMIT OF LIABILITY:ApplicableNot ApplicableOnly those coverage features marked “ Applicable” are included in this policy.FORMS AND ENDORSEMENTS ATTACHED AT ISSUANCE:THE DECLARATIONS, THE APPLICATION, THE LIABILITY COVERAGE TERMS AND CONDITIONS, THISLIABILITY COVERAGE, AND ANY ENDORSEMENTS ATTACHED THERETO, CONSTITUTE THE ENTIREAGREEMENT BETWEEN THE COMPANY AND THE INSURED._____________________________Countersigned ByIN WITNESS WHEREOF, the Company has caused this policy to be signed by its authorized officers.Executive Vice PresidentCorporate SecretarySpecimenFRI-2001 Ed. 01-09 Printed in U.S.A. Page 3 of 3©2009 The Travelers Companies, Inc. All Rights Reserved