FULLY PAID AND NON-ASSESSABLECOMMON SHARES OF PAR VALUE US$[ ] EACH
Exhibit 4.1
| [GRAPHIC] | GEOVERA INSURANCE HOLDINGS, LTD. | [GRAPHIC] | ||
| ORGANISED UNDER THE LAWS OF BERMUDA | SEE REVERSE SIDE FOR CERTAIN DEFINITIONS | |||
| CUSIP 000000 00 0 | ||||
THIS CERTIFIES THAT
is the owner of
FULLY PAID AND NON-ASSESSABLE COMMON SHARES OF PAR VALUE US$[ ]
EACH
GeoVera Insurance Holdings, Ltd. (hereinafter called the “Company”), transferable on the books of the Company in person or by duly authorized attorney, upon surrender of this Certificate properly endorsed. This Certificate and the shares represented hereby, are issued and shall be held subject to all of the provisions of the Memorandum of Association and the Bye-Laws of the Company (copies of which are on file with the Company and with the Transfer Agent), to all of which each holder, by acceptance hereof, assents. This certificate is not valid unless countersigned and registered by the Transfer Agent and Registrar.
Witness the facsimile seal of the Company and the facsimile signature of its duly authorized officers.
Dated:
| SECRETARY | PRESIDENT |
| COUNTERSIGNED AND REGISTERED: | ||||
| WELLS FARGO BANK, N.A. TRANSFER AGENT AND REGISTRAR | ||||
| BY | ||||
| AUTHORIZED SIGNATURE | ||||
The following abbreviations, when used in the inscription on the face of this certificate, shall be construed as though they were written out in full according to applicable laws or regulations:
| UTMA – | Custodian | |||||||||||
| TEN COM | – | as tenants in common | (Cust) | (Minor) | ||||||||
| under Uniform Transfers to Minors Act | ||||||||||||
| TEN ENT | – | as tenants by entireties | (State) | |||||||||
| JT TEN | – | as joint tenants with right of survivorship and not as tenants in common | ||||||||||
| Additional abbreviations may also be used though not in above list. | ||||||||||||
For value received hereby sell, assign, and transfer unto
| PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER OF ASSIGNEE |
| (PLEASE PRINT OR TYPEWRITE NAME AND ADDRESS INCLUDING ZIP CODE OF ASSIGNEE) |
Shares represented by the within Certificate, and do hereby irrevocably constitute and appoint
Attorney to transfer the said shares on the books of the within-named Company with full power of substitution in the premises.
| Dated | X | |||||||
| X | ||||||||
| NOTICE: THE SIGNATURE TO THIS ASSIGNMENT MUST CORRESPOND WITH THE NAME AS WRITTEN UPON THE FACE OF THE CERTIFICATE IN EVERY PARTICULAR WITHOUT ALTERATION OR ENLARGEMENT OR ANY CHANGE WHATEVER. | ||||||||
SIGNATURE(S) GUARANTEED:
THE SIGNATURE(S) MUST BE GUARANTEED BY AN ELIGIBLE GUARANTOR INSTITUTION (BANKS, STOCKBROKERS, SAVINGS AND LOAN ASSOCIATIONS AND CREDIT UNIONS WITH MEMBERSHIP IN AN APPROVED SIGNATURE GUARANTEE MEDALLION PROGRAM), PURSUANT TO S.E.C. RULE 17Ad-15.
