SURPLUS DISCLAIMER STATEMENT

The undersigned insured hereby acknowledges:

A. I understand the insurance coverage provided by this policy is written by a non-licensed insurer for the State of Alabama. I further understand no Guaranty Fund protection exists in the event insolvency occurs to this non-licensed insurer.

B. After understanding the advantage and disadvantages of securing insurance coverage through the non-licensed insurer, I with knowledge and consent do hereby authorize and request Southern Alabama Insurance Agency to place such coverage with the Lloyds of London.

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The Insured (printed) Date

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Signature Title

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Agent Date

Remit to:

Southern Alabama Insurance

P.O. BOX 3768

Gulf Shores, Al 36547

PH 251-968-7146

FAX 251-968-5438

Approved by Alabama Department of Insurance 11/10/92