REINSURANCE SUMMARY STATEMENT

________________________________________________INSURANCE COMPANY

TREATY NUMBER ____________ DATE FILED WITH FL DEPARTMENT

EFFECTIVE DATE ____________EXPIRATION

COMPANY(IES) CEDED TO:________________________________________________    _____%

__________________________________      _________%_________________________________________ %

__________________________________%   ________ % _________________________________________%

BROKER:__________________________     BROKERAGE FEE:___________________________________%

TYPE OF TREATY:

TYPES OF RISKS COVERED:

RETENTION LIMITS:

REINSURER'S LIMITS:

TERRITORIAL LIMIT:

COMMISSION:

EXPENSE ALLOWANCE:

PROFIT COMMISSION: (IF APPLICABLE)

DEPOSIT PREMIUM:

REPORT REQUIREMENTS:

REMITTANCE REQUIREMENTS:

PORTFOLIO TREATIES

        ENTRY DATE AND AMOUNT CEDED:

        WITHDRAWAL DATE:

        UNEARNED PREMIUM TRANSFER (YES OR NO)

        LOSS PORTFOLIO TRANSFER (YES OR NO)

CANCELLATION PROVISIONS:

SPECIAL CLAUSES:

OTHER CONDITIONS:

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NOTARY PUBLIC COMPANY OFFICER                                                COMPANY OFFICER