Expatriates Health Insurance

Effected through
JOHN A. COSTA
COSTA INSURANCE BROKER
11867 102ND STREET N.
LARGO, FLORIDA 33773
FLORIDA LICENSE #128303135003
TELEPHONE #(727) 392-6229
FAX #(727) 391-0562

This is to Certify that in accordance with the authorization granted
under the Contract (the number of which is specified in the Schedule) to the
undersigned by certain Underwriters at Lloyd's, whose names and the proportions
underwritten by them, which will be supplied on application, can be ascertained
by reference to the said Contract which bears the Seal of Lloyd's Policy Signing
Office, and in consideration of the premium specified herein, the said Underwriters
are hereby bound, each for his own part and not one for another, their Heirs,
Executors and Administrators, to insure in accordance with the terms and conditions
contained herein or endorsed hereon.

The Underwriters hereby agree. to insure against loss including but
not limited to associated expenses specified herein, if any, to the extent and in
the manner herein provided.

If the Assured shall make any claim knowing the same to be false or fraudulent,
as regards amount or otherwise, this Certificate shall become void and all claim
hereunder shall be forfeited.

In Witness whereof this Certificate has been signed at the place stated and
on the date specified in the Schedule.

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