SAMPLE CLAIM FORM

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					                                                                             CLAIM FORM

GORDIAN RUNOFF (UK) LIMITED, FORMERLY GIO (UK) LIMITED
For each claim arising under a Reinsurance Contract, in relation to which you are a Scheme Creditor, please complete this Claim Form following the instructions on the
following pages. You should read the instructions carefully and note that the Claim Form is to be completed with the position as at the Ascertainment Date, 31
December 2005. The numbers at the head of the columns correspond to the numbered instructions contained on the following pages of this form.

THIS CLAIM FORM, ALONG WITH APPROPRIATE SUPPORTING INFORMATION, MUST BE RETURNED TO GORDIAN RUNOFF (UK) LIMITED, ONE GREAT TOWER
STREET, LONDON, EC3A 5AH, UNITED KINGDOM, MARKED FOR THE ATTENTION OF ANDREW GODWIN AS SOON AS POSSIBLE AND BY NO LATER THAN THE
FINAL CLAIMS SUBMISSION DATE, NAMELY 11:59pm ON WEDNESDAY 25 OCTOBER 2006, AFTER WHICH NO NEW OR REVISED CLAIM FORM(S) WILL BE
ADMITTED, OR REVISED OR FURTHER INFORMATION ACCEPTED, EXCEPT IN THE LATTER CASE IN RESPONSE TO A REQUEST FROM THE SCHEME MANAGER,
THE SCHEME ACTUARY OR THE SCHEME ADJUDICATOR OR IN RELATION TO A SUBSTANTIVE JUDGMENT.

SCHEME CREDITOR NAME: ……………………………………………………………………………………………………………………………………………………………….
SCHEME CREDITOR ADDRESS: ………………………………………………………………………………………………………………………………………………………….
SCHEME CREDITOR TELEPHONE NUMBER: ……………………………………………….………………………………………………………………………………………….
SCHEME CREDITOR E-MAIL ADDRESS: ……………………………………………………..………………………………………………………………………………………….
CURRENCY:                          Please complete a separate Claim Form for each currency. Use photocopied pages as required.

(1)            (2)             (3)            (4)            (5)            (6)             (7)               (8)            (8a)       (9)             (10)
Reinsurance    Participation   Inception      Relevant       Relevant       Paid Losses     Notified          IBNR Claims    Basis      Set-off         Total
Contract       Percentage      Date           Broker         Broker                         Outstanding                      of                         (6+7+8-9)
reference      (%)                                           Reference                      Claims                           IBNR
number                                                                                                                       Claims




                                                      COLUMN TOTALS


 To the best of my knowledge and belief the information on this Claim Form and any supporting schedules, as amended or otherwise, is correct.

 Signed: …………………………………………………………………………………………………………                                                           Name: …………………………………………………………
 Position/Capacity: ………………………………………………………………………..…………………...
 For and on behalf of (Scheme Creditor name) ……………………………………………………….….                                       Date: ……………………………….………………………….
INSTRUCTIONS FOR COMPLETION OF THE CLAIM FORM

Please note that the terms used within these instructions and in the Claim Form bear the same meanings as given to them in the Scheme of
Arrangement. The numbers below refer to the numbered columns in the Claim Form. If in relation to a Reinsurance Contract you have any
claims in more than one currency, please photocopy the table and use a separate table for each currency, specifying in the box provided the
relevant currency. If there are insufficient lines for any one currency, please photocopy the table and complete the photocopy. Please refer to
pages 17 and 18 of the Scheme document for further details on completing the Claim Form and the supporting evidence required.

(1) Reinsurance Contract reference number
Please specify each Reinsurance Contract reference number under which each of your claims may arise against the Scheme Company, and
provide a copy of the policy schedule or cover note and the schedule of reinsurers with particulars of each claim in supporting schedules
(where applicable). Your broker will be able to assist you in confirming or identifying additional Reinsurance Contracts and reference numbers.
Please then insert the Reinsurance Contract reference numbers on the Claim Form using a separate line for each.

(2) Participation percentage
The participation percentage for each Reinsurance Contract represents the percentage line underwritten or assumed by the Scheme Company
under the Reinsurance Contract. Insert the percentage line for each Reinsurance Contract (apportioning the value of each of your claims
against the Scheme Company accordingly when completing columns (6), (7) and (8)) and if the percentage is not of 100% state what it is a
percentage of.

(3) Inception date
Specify the date when each Reinsurance Contract commenced. In the case of continuous Reinsurance Contracts or Reinsurance Contracts of
more than 12 months, each anniversary or renewal should be shown as a separate Reinsurance Contract.

(4) Relevant Broker
Specify the name of the broker who placed the Reinsurance Contract or, if the placing broker is not known, any other broker or intermediary (if
known) who acted on your behalf in relation to the Reinsurance Contract. Enter, in addition, either "Placing" or "Other" as applicable.

(5) Relevant Broker reference
Specify the broker's contract reference for each Reinsurance Contract.

(6) Paid Losses
Specify the amount of any claim or (where there is more than one claim) the aggregate amount of claims against you or your liabilities in
respect of losses that are certain in amount, have been paid by you to your insured or are due and payable by you to your insured, arising
under each Reinsurance Contract that has/have been established by agreement, or otherwise. Please note that Claims Agreed Pre-Scheme
(i.e. claims submitted by you to the Scheme Company and accepted as agreed on the CLASS system by the Scheme Company as at the
Effective Date) do not have to be included on this Claim Form. See paragraph 4.12 of the Explanatory Statement and clause 15.3 of the
Scheme.
(7) Notified Outstanding Claims
Specify the estimated amount of any claim or (where there is more than one claim) the aggregate estimated amount of any claims or liabilities
that you have, arising under each Reinsurance Contract in respect of losses which have been notified you but have not yet become Paid
Losses and provide particulars of your estimate(s) in supporting schedules in accordance with the Scheme.

(8) IBNR claims
Specify the estimated amount or (where there is more than one claim) the aggregate estimated amount of any claims that you have, arising
under each Reinsurance Contract that has/have been incurred but not yet reported and provide particulars of your estimate(s) in supporting
schedules in accordance with the Scheme.

(8a) Basis of IBNR claims
Your estimate(s) may be based on:
A the development of paid claims under the Reinsurance Contract; or
B the development of incurred claims under the Reinsurance Contract (i.e. Paid Losses together with known Notified Outstanding claims); or
C the development of the ratio of incurred losses to the total premiums under the Reinsurance Contract (i.e. the incurred loss ratio); or
D any other generally accepted actuarial basis, which must be specified.
Enter A, B, C or D as appropriate in column (8a) and provide particulars of your estimate(s) (which may include actuarial analysis) in supporting
schedules in accordance with the Scheme (please refer to pages 108 and 109 of the Scheme document for further details).

(9) Set-off, Security Interests, Letters of Credit or any other counter-claims
Specify the estimated amount or (where there is more than one claim) the aggregate estimated amount of any set-off, Security Interest, Letter
of Credit, trust or cross-claim that you believe exists in relation to each Reinsurance Contract under each claim(s) and which is available in
respect of such claim(s). Provide an analysis of the amount and provide any supporting documentation, including bank references in respect of
Letters of Credit.

(10) Total
In column 10, enter the total of columns (6), (7) and (8) less column (9). Enter the total sum of all column (10) amounts at the foot of column 10.

You are requested to return the Claim Form, together with supporting schedules, to Gordian RunOff (UK) Limited, One Great Tower
Street, London, EC3A 5AH, United Kingdom, marked for the attention of Andrew Godwin by the Final Claims Submission Date,
namely 11:59pm on Wednesday 25 October 2006.

				
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