Document:

Exhibit 4.1

 

FORM OF UNIT PURCHASE WARRANT

 

THIS WARRANT AND THE SECURITIES ISSUABLE
UPON THE EXERCISE OF THIS WARRANT HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE SECURITIES ACT”).
EXCEPT AS OTHERWISE SET FORTH HEREIN OR IN A SECURITIES PURCHASE AGREEMENT DATED AS OF FEBRUARY 22, 2018 (THE “SECURITIES
PURCHASE AGREEMENT”), NEITHER THIS WARRANT NOR ANY OF THE SECURITIES ISSUABLE UPON THE EXERCISE OF THIS WARRANT MAY BE SOLD,
TRANSFERRED OR ASSIGNED IN THE ABSENCE OF AN EFFECTIVE REGISTRATION STATEMENT FOR SUCH SECURITIES UNDER THE SECURITIES ACT OR AN
OPINION OF COUNSEL, IN FORM, SUBSTANCE AND SCOPE, CUSTOMARY FOR OPINIONS OF COUNSEL IN COMPARABLE TRANSACTIONS, THAT REGISTRATION
IS NOT REQUIRED UNDER THE SECURITIES ACT, THE SUBSTANCE OF WHICH OPINION SHALL BE REASONABLY ACCEPTABLE TO THE COMPANY.

 

Warrant to Purchase Units, with each
Unit Consisting of One Share of Common Stock

and One Warrant to Purchase One Share
of Common Stock

 

Issue Date: July 31, 2018

 

ADIAL PHARMACEUTICALS, INC.

 

UNIT PURCHASE WARRANT

 

THIS CERTIFIES THAT,
for value received, ___________________ or his, her or its assigns (“Holder”), is entitled to purchase
from Adial Pharmaceuticals, Inc., a Delaware corporation (the “Company”), at any time or from time to
time during the period specified in Paragraph 2 hereof and subject to adjustment as provided herein, _________ units
(each a “Unit” and collectively, the “Units”), with each Unit consisting of one share of
the Company’s common stock, par value $0.001 per share (the “Common Stock”), and one warrant (each a “Common
Warrant” and collectively, the “Common Warrants”) to purchase one share of Common Stock. The form
of Common Warrant is attached hereto as Exhibit A. The exercise price per Unit is $5.00 (the “Exercise Price”).
The term “Warrant Shares” as used herein, refers to the shares of Common Stock purchasable under this Warrant
and the term “Common Warrant Shares” as used herein, refers to the shares of Common Stock purchasable under
any Common Warrant that may be issued under this Warrant. The Warrant Shares and the Exercise Price are subject to adjustment as
provided in Paragraph 4 hereof. The term “Warrant” means this Unit Purchase Warrant issued pursuant to that
certain Securities Purchase Agreement, dated February 22, 2018, by and among the Company and the Investors listed on the execution
pages thereof (the “Securities Purchase Agreement”).

 

In addition to the
terms and conditions set forth herein, this Warrant is subject to the terms and conditions of the Securities Purchase Agreement.

 

     

     

    

 

This Warrant is subject to the following
terms, provisions, and conditions:

 

1. Manner
of Exercise; Issuance of Certificates; Payment for Units. Subject
to the provisions hereof, this Warrant may be exercised by the Holder, in whole or in part, by the surrender of this Warrant,
together with a completed exercise agreement in the form attached hereto as Exhibit B (the “Exercise
Agreement”), to the Company during normal business hours on any business day at the Company’s principal
executive offices (or such other office or agency of the Company as it may designate by notice to the Holder), and upon
payment to the Company in cash, by certified or official bank check or by wire transfer for the account of the Company of the
Exercise Price for the Units specified in the Exercise Agreement or by “cashless exercise” for the Units as
provided below. The Units so purchased shall be deemed to be issued to the Holder or such Holder’s designee, as the
record owner of such Warrant Shares and accompanying Common Warrants that comprise the Units, as of the close of business on
the date on which this Warrant shall have been surrendered, the completed Exercise Agreement shall have been delivered, and
payment shall have been made for such Units as set forth above. Certificates for the Warrant Shares and Common Warrants
comprising the Units so purchased, representing the aggregate number of Warrant Shares and Common Warrants specified in the
Exercise Agreement, shall be delivered to the Holder within a reasonable time, not exceeding three (3) business days, after
this Warrant shall have been so exercised. If this Warrant shall have been exercised only in part, then, unless this Warrant
has expired, the Company shall, at its expense, at the time of delivery of such certificates, deliver to the Holder a new
Warrant representing the number of Units with respect to which this Warrant shall not then have been exercised. 

 

This Warrant may also
be exercised at such time by means of a “cashless exercise” in which the Holder shall be entitled to receive a number
of Units equal to the quotient obtained by dividing [(A-B) (X)] by (A), where:

 

(A) = the
average VWAP on the thirty (30) Trading Days immediately preceding the date on which Holder elects to exercise this Warrant by
means of a “cashless exercise,” as set forth in the applicable Notice of Exercise;

 

(B) = the
Exercise Price of this Warrant, as adjusted; and

 

(X) =
the number of Units issuable upon exercise of this Warrant in accordance with the terms of this Warrant by means of a cash exercise
rather than a cashless exercise.

 

For purposes of this calculation, the Common
Warrant included in each Unit shall be disregarded and full value shall be attributable to the shares of Common Stock included
in the Units.

 

“VWAP”
means, for any Trading Day, the price determined by the first of the following clauses that applies: (a) if Common Stock is then
traded or quoted on the Trading Market, the daily volume weighted average price of Common Stock for such Trading Day on the Trading
Market; (b) if Common Stock is not then traded or quoted on the Trading Market and if prices for Common Stock are then reported
in the “Pink Sheets” published by Pink Sheets, LLC (or a similar organization or agency succeeding to its functions
of reporting prices), the most recent bid price per share of Common Stock so reported as of such Trading Day; or (c) in all other
cases, the fair market value of a share of Common Stock as of such Trading Day, as determined by an independent appraiser selected
in good faith by the Holder and reasonably acceptable to the Company.

 

    	 	2	 

     

    

 

“Trading Day”
means, at any time, a day on which the Trading Market is open for the general trading or quotation of securities and Common Stock
is traded or quoted thereon or, if Common Stock is not then traded or quoted on the Trading Market, a business day.

 

“Trading Market”
means, at any time, the securities exchange, quotation system or over-the-counter trading facility on which Common Stock is principally
traded or quoted at such time.

 

[Notwithstanding anything
in this Warrant to the contrary, in no event shall the Holder be entitled to exercise this Warrant, either in whole or in part,
to obtain a number of Warrant Shares that would result in beneficial ownership by the Holder and its affiliates of more than 4.9%
of the outstanding shares of Common Stock. For purposes of the immediately preceding sentence, beneficial ownership shall be determined
in accordance with Section 13(d) of the Securities Exchange Act of 1934, as amended, and Regulation 13D-G thereunder. Notwithstanding
anything to the contrary contained herein, the limitation on exercise of this Warrant set forth herein may not be amended without
(i) the written consent of the Holder and the Company and (ii) the approval of a majority of shareholders of the Company.]1

 

2. Period
of Exercise. This Warrant is
exercisable at any time or from time to time on or after July 31, 2018 and delivered pursuant to the terms of the Securities
Purchase Agreement and before 5:00 p.m., New York, New York time on July 31, 2023, the fifth (5th) anniversary of the date of
issuance (the “Exercise Period”). 

 

3. Certain
Agreements of the Company. The
Company hereby covenants and agrees as follows:

 

(a) Shares
to be Fully Paid. All Warrant Shares and Common Warrant Shares will, upon issuance in accordance with the terms of this
Warrant and the Common Warrant, be validly issued, fully paid, and nonassessable and free from all taxes, liens, and charges with
respect to the issue thereof.

 

(b) Reservation
of Shares. During the Exercise Period, the Company shall at all times have authorized, and reserved for the purpose
of issuance upon exercise of this Warrant, a sufficient number of shares of Common Stock to provide for the exercise in full
of this Warrant and any Common Warrant issued.

 

(c) Successors
and Assigns. This Warrant will be binding upon any entity succeeding to the Company by merger, consolidation, or
acquisition of all or substantially all the Company’s assets.

 

 

1
Applies to the Company’s non-insiders only.

 

    	 	3	 

     

    

 

4. Antidilution
Provisions. During the
Exercise Period, the Exercise Price and the number of Warrant Shares and Common Warrants comprising the Units shall be
subject to adjustment from time to time as provided in this Paragraph 4.

 

In the event that any
adjustment of the Exercise Price as required herein results in a fraction of a cent, such Exercise Price shall be rounded up to
the nearest cent.

 

(a) Subdivision
or Combination of Common Stock. If the Company at any time subdivides (by any stock split, stock dividend,
recapitalization, reorganization, reclassification or otherwise) the shares of Common Stock into a greater number of shares,
then, after the date of record for effecting such subdivision, the number of Warrant Shares issuable hereunder and the number
of Common Warrant Shares issuable under the Common Warrant will be proportionately increased and the exercise price of the
underlying Common Warrant in effect immediately prior to such subdivision will be proportionately reduced. If the Company at
any time combines (by reverse stock split, recapitalization, reorganization, reclassification or otherwise) the shares of
Common Stock into a smaller number of shares, then, after the date of record for effecting such combination and the number of
Common Warrant Shares issuable under the Common Warrant will be proportionately reduced and the exercise price of the
underlying Common Warrant in effect immediately prior to such combination will be proportionately increased. The increases
and reductions provided for in this Section 4(a) will be made with the intent and, as nearly as practicable, the effect that
neither the percentage of the total equity of the Company obtainable on exercise of this Warrant nor the price payable for
such percentage upon such exercise will be affected by any event described in this Section 4(a).

 

(b) Adjustment
in Number of Units. Upon each adjustment of the Exercise Price pursuant to the provisions of this Paragraph 4, the
number of Units issuable upon exercise of this Warrant shall be adjusted by multiplying a number equal to the Exercise Price
in effect immediately prior to such adjustment by the number of Units issuable upon exercise of this Warrant immediately
prior to such adjustment and dividing the product so obtained by the adjusted Exercise Price. The increases and reductions
provided for in this Section 4(b) will be made with the intent and, as nearly as practicable, the effect that neither the
percentage of the total equity of the Company obtainable on exercise of this Warrant nor the price payable for such
percentage upon such exercise will be affected by any event described in this Section 4(b).

 

(c) Consolidation,
Merger or Sale. In case of any consolidation of the Company with, or merger of the Company into any other corporation
or other entity, or in case of any sale or conveyance of all or substantially all of the assets of the Company other than in
connection with a plan of complete liquidation of the Company, then as a condition of such consolidation, merger or sale or
conveyance, adequate provision will be made whereby the Holder of this Warrant will have the right to acquire and receive
upon exercise of this Warrant in lieu of the Units immediately theretofore acquirable upon the exercise of this Warrant, such
shares of stock, securities or assets as would be issued or payable with respect to or in exchange for the number of Units or
other securities purchasable upon exercise of this Warrant immediately theretofore acquirable and receivable upon exercise of
this Warrant in connection with such consolidation, merger or sale or conveyance. In any such case, the Company will make
appropriate provision to ensure that the provisions of this Paragraph 4 hereof will thereafter be applicable as nearly as may
be in relation to any shares of stock or securities thereafter deliverable upon the exercise of this Warrant. The Company
will not effect any consolidation, merger or sale or conveyance unless prior to the consummation thereof, the successor
corporation or other entity (if other than the Company) assumes by written instrument the obligations under this Paragraph
4(c) and the obligations to deliver to the Holder of this Warrant such shares of stock, securities or assets as, in
accordance with the foregoing provisions, the Holder may be entitled to acquire.

 

    	 	4	 

     

    

 

5. Issue
Tax. The issuance of
certificates for Warrant Shares and Common Warrants upon the exercise of this Warrant shall be made without charge to the
Holder of this Warrant or such shares for any issuance tax or other costs in respect thereof, provided that the Company shall
not be required to pay any tax which may be payable in respect of any transfer involved in the issuance and delivery of any
certificate in a name other than the Holder of this Warrant.

 

6. No
Rights or Liabilities as a Shareholder. This
Warrant shall not entitle the Holder to any voting rights or other rights as a shareholder of the Company. No provision of
this Warrant, in the absence of affirmative action by the Holder to purchase Warrant Shares, and no mere enumeration herein
of the rights or privileges of the Holder, shall give rise to any liability of such Holder for the Exercise Price or as a
shareholder of the Company, whether such liability is asserted by the Company or by creditors of the
Company.

 

7. Transfer,
Exchange, and Replacement of Warrant.

 

(a) Restriction
on Transfer. This Warrant and the rights granted to the Holder are transferable, in whole or in part, upon surrender
of this Warrant, together with a properly executed assignment in the form attached hereto as Exhibit C, at the office
or agency of the Company, provided, however, that any transfer or assignment shall be subject to the conditions set forth in
Paragraph 7(f) hereof and to the applicable provisions of the Securities Purchase Agreement. Until due presentment for
registration of transfer on the books of the Company, the Company may treat the registered Holder as the owner and Holder for
all purposes, and the Company shall not be affected by any notice to the contrary. Notwithstanding the above, Holder may
subdivide this warrant (i.e. transfer it in part) no more than three (3) times without the written consent of the Company in
its sole discretion.

 

(b) Warrant
Exchangeable for Different Denominations. This Warrant is exchangeable, upon the surrender hereof by the Holder at the
office or agency of the Company, for new Warrants of like tenor representing in the aggregate the right to purchase the number
of Units that which may be purchased hereunder, each of such new Warrants to represent the right to purchase such number of shares
as shall be designated by the Holder at the time of such surrender.

 

(c) Replacement
of Warrant. Upon receipt of evidence reasonably satisfactory to the Company of the loss, theft, destruction, or
mutilation of this Warrant and, in the case of any such loss, theft, or destruction, upon delivery of an indemnity agreement
reasonably satisfactory in form and amount to the Company, or, in the case of any such mutilation, upon surrender and
cancellation of this Warrant, the Company, at its expense, will execute and deliver, in lieu thereof, a new Warrant of like
tenor.

 

(d) Cancellation;
Payment of Expenses. Upon the surrender of this Warrant in connection with any transfer, exchange, or replacement as
provided in this Paragraph 7, this Warrant shall be promptly canceled by the Company. The Company shall pay all taxes (other
than securities transfer taxes) and all other expenses (other than legal expenses, if any, incurred by the Holder or
transferees) and charges payable in connection with the preparation, execution, and delivery of Warrants pursuant to this
Paragraph 7.

 

    	 	5	 

     

    

 

(e) Register.
The Company shall maintain, at its principal executive offices (or such other office or agency of the Company as it may
designate by notice to the Holder), a register for this Warrant, in which the Company shall record the name and address of
the person in whose name this Warrant has been issued, as well as the name and address of each transferee and each prior
owner of this Warrant.

 

(f) Exercise
or Transfer Without Registration. If, at the time of the surrender of this Warrant in connection with any exercise, transfer,
or exchange of this Warrant, this Warrant (or, in the case of any exercise, the Warrant Shares and Common Warrants issuable hereunder),
shall not be registered under the Securities Act of 1933, as amended (the “Securities Act”), and under applicable
state securities or blue sky laws, the Company may require, as a condition of allowing such exercise, transfer, or exchange, (i)
that the Holder or transferee of this Warrant, as the case may be, furnish to the Company a written opinion of counsel, which opinion
and counsel are reasonably acceptable to the Company, to the effect that such exercise, transfer, or exchange may be made without
registration under the Securities Act and under applicable state securities or blue sky laws, (ii) that the Holder or transferee
execute and deliver to the Company an investment letter in form and substance acceptable to the Company and (iii) that the transferee
be an “accredited investor” as defined in Rule 501(a) promulgated under the Securities Act; provided that no such opinion,
letter or status as an “accredited investor” shall be required in connection with a transfer pursuant to Rule 144 under
the Securities Act. The first holder of this Warrant, by taking and holding the same, represents to the Company that such holder
is acquiring this Warrant for investment and not with a view to the distribution thereof. In no event shall the Holder be permitted
to assign the Warrant unless provided with express written consent by the Company.

 

8.
[Intentionally Omitted]

 

9. Notices. All
notices, requests, and other communications required or permitted to be given or delivered hereunder to the Holder of this
Warrant shall be in writing, and shall be personally delivered, or shall be sent by certified or registered mail or by
recognized overnight mail courier, postage prepaid and addressed, to such holder at the address shown for such holder on the
books of the Company, or at such other address as shall have been furnished to the Company by notice from such holder. All
notices, requests, and other communications required or permitted to be given or delivered hereunder to the Company shall be
in writing, and shall be personally delivered, or shall be sent by certified or registered mail or by recognized overnight
mail courier, postage prepaid and addressed, to the office of the Company at the address set forth in the Securities Purchase
Agreement, or at such other address as shall have been furnished to the Holder of this Warrant by notice from the Company.
Any such notice, request, or other communication may be sent by facsimile, but shall in such case be subsequently confirmed
by a writing personally delivered or sent by certified or registered mail or by recognized overnight mail courier as provided
above. All notices, requests, and other communications shall be deemed to have been given either at the time of the
receipt thereof by the person entitled to receive such notice at the address of such person for purposes of this Paragraph 9,
or, if mailed by registered or certified mail or with a recognized overnight mail courier upon deposit with the United States
Post Office or such overnight mail courier, if postage is prepaid and the mailing is properly addressed, as the case may
be.

 

    	 	6	 

     

    

 

10. Governing
Law. THIS WARRANT SHALL BE
ENFORCED, GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH THE LAWS OF THE STATE OF DELAWARE APPLICABLE TO AGREEMENTS MADE AND TO
BE PERFORMED ENTIRELY WITHIN SUCH STATE, WITHOUT REGARD TO THE PRINCIPLES OF CONFLICT OF LAWS. THE PARTIES HERETO HEREBY
SUBMIT TO THE EXCLUSIVE JURISDICTION OF THE UNITED STATES FEDERAL COURTS LOCATED IN NEW YORK, NEW YORK WITH RESPECT TO ANY
DISPUTE ARISING UNDER THIS WARRANT, THE AGREEMENTS ENTERED INTO IN CONNECTION HEREWITH OR THE TRANSACTIONS CONTEMPLATED
HEREBY OR THEREBY. BOTH PARTIES IRREVOCABLY WAIVE THE DEFENSE OF AN INCONVENIENT FORUM TO THE MAINTENANCE OF SUCH SUIT OR
PROCEEDING. BOTH PARTIES FURTHER AGREE THAT SERVICE OF PROCESS UPON A PARTY MAILED BY FIRST CLASS MAIL SHALL BE DEEMED IN
EVERY RESPECT EFFECTIVE SERVICE OF PROCESS UPON THE PARTY IN ANY SUCH SUIT OR PROCEEDING. NOTHING HEREIN SHALL AFFECT EITHER
PARTY’S RIGHT TO SERVE PROCESS IN ANY OTHER MANNER PERMITTED BY LAW. BOTH PARTIES AGREE THAT A FINAL NON-APPEALABLE
JUDGMENT IN ANY SUCH SUIT OR PROCEEDING SHALL BE CONCLUSIVE AND MAY BE ENFORCED IN OTHER JURISDICTIONS BY SUIT ON SUCH
JUDGMENT OR IN ANY OTHER LAWFUL MANNER. THE PARTY WHICH DOES NOT PREVAIL IN ANY DISPUTE ARISING UNDER THIS WARRANT SHALL BE
RESPONSIBLE FOR ALL FEES AND EXPENSES, INCLUDING ATTORNEYS’ FEES, INCURRED BY THE PREVAILING PARTY IN CONNECTION WITH
SUCH DISPUTE.

 

11. Miscellaneous.

 

(a) Amendments;
Waivers. No purported amendment to any provision of this Warrant shall be binding on the parties unless each party
has duly executed and delivered to the other party a written instrument which states that it constitutes an amendment to this
Warrant and specifies the provision(s) hereof that are being amended. No purported waiver of any provision of this Warrant
shall be binding on any party unless it has duly executed and delivered to the other party a written instrument which states
that it constitutes a waiver of one or more provisions of this Warrant and specifies the provision(s) hereof that are being
waived. Any such waiver shall be effective only to the extent specifically set forth in such written instrument. No waiver of
any right, power or remedy of a party shall be deemed to be a waiver of any other right, power or remedy of such party or
shall, except to the extent so waived, impair, limit or restrict the exercise of such right, power or remedy.

 

(b) Descriptive
Headings. The descriptive headings of the several paragraphs of this Warrant are inserted for purposes of reference
only, and shall not affect the meaning or construction of any of the provisions hereof.

 

(c) Fractional
Units/Securities. No fractional Units or other securities will be issued in connection with the exercise of this
Warrant, and the number of Warrant Shares and Common Warrants comprising the Units to be issued shall be rounded to the
nearest whole number.

 

(d) Remedies.
The Company acknowledges that a breach by it of its obligations hereunder will cause irreparable harm to the Holder, by
vitiating the intent and purpose of the transaction contemplated hereby. Accordingly, the Company acknowledges that the
remedy at law for a breach of its obligations under this Warrant will be inadequate and agrees, in the event of a breach or
threatened breach by the Company of the provisions of this Warrant, that the Holder shall be entitled, in addition to all
other available remedies at law or in equity, and in addition to the penalties assessable herein, to an injunction or
injunctions restraining, preventing or curing any breach of this Warrant and to enforce specifically the terms and provisions
thereof, without the necessity of showing economic loss and without any bond or other security being required.

 

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    	 	7	 

     

    

 

IN WITNESS WHEREOF,
the Company has caused this Warrant to be signed by its duly authorized officer.

 

	 	ADIAL PHARMACEUTICALS, INC.
	 	 
	 	By:	 
	 	Name:	William B. Stilley
	 	Title:	Chief Executive Officer

 

Dated as of: July 31, 2018

 

     

     

    

 

Exhibit A

 

FORM OF COMMON STOCK PURCHASE WARRANT

 

THIS WARRANT AND THE SHARES ISSUABLE
UPON THE EXERCISE OF THIS WARRANT HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED. EXCEPT AS OTHERWISE SET
FORTH HEREIN OR IN A SECURITIES PURCHASE AGREEMENT DATED AS OF FEBRUARY 22, 2018 (THE “SECURITIES PURCHASE AGREEMENT”),
NEITHER THIS WARRANT NOR ANY OF SUCH SHARES MAY BE SOLD, TRANSFERRED OR ASSIGNED IN THE ABSENCE OF AN EFFECTIVE REGISTRATION STATEMENT
FOR SUCH SECURITIES UNDER THE SECURITIES ACT OR AN OPINION OF COUNSEL, IN FORM, SUBSTANCE AND SCOPE, CUSTOMARY FOR OPINIONS OF
COUNSEL IN COMPARABLE TRANSACTIONS, THAT REGISTRATION IS NOT REQUIRED UNDER THE SECURITIES ACT, THE SUBSTANCE OF WHICH OPINION
SHALL BE REASONABLY ACCEPTABLE TO THE COMPANY.

 

Right
to Purchase _______ shares of Common Stock, par value $0.001 per share

 

COMMON STOCK PURCHASE WARRANT

 

THIS CERTIFIES
THAT, for value received, ___________________ or his, her or its assigns (“Holder”),
is entitled to purchase from Adial Pharmaceuticals, Inc., a Delaware corporation (the
“Company”), at any time or from time to time during the period specified in Paragraph 2 hereof and subject
to adjustment as provided herein, _________ fully paid and nonassessable shares of the Company’s Common Stock, par value
$0.001 per share (the “Common Stock”), at an exercise price per share equal to $6.25 per share of Common Stock
(the “Exercise Price”). The term “Warrant Shares,” as used herein, refers to the shares of
Common Stock purchasable hereunder. The Warrant Shares and the Exercise Price are subject to adjustment as provided in Paragraph
4 hereof. The term “Warrant” means this Common Stock Purchase Warrant issued pursuant to that certain Securities
Purchase Agreement, dated February 22, 2018, by and among the Company and the Investors listed on the execution pages thereof (the
“Securities Purchase Agreement”) and the Unit Warrant issued to Holder on July 31, 2018. In addition to the
terms and conditions set forth herein, this Warrant is subject to the terms and conditions of the Securities Purchase Agreement.

 

This
Warrant is subject to the following terms, provisions, and conditions: 

 

1.
Manner of Exercise; Issuance of Certificates; Payment for Shares. Subject to the provisions
hereof, this Warrant may be exercised by the Holder, in whole or in part, by the surrender of this Warrant, together with a completed
exercise agreement in the form attached hereto (the “Exercise Agreement”), to the Company during normal business
hours on any business day at the Company’s principal executive offices (or such other office or agency of the Company as
it may designate by notice to the Holder), and upon payment to the Company in cash, by certified or official bank check or by
wire transfer for the account of the Company of the Exercise Price for the Warrant Shares specified in the Exercise Agreement
or by “cashless exercise” as provided below. The Warrant Shares so purchased shall be deemed to be issued to the Holder
or such Holder’s designee, as the record owner of such shares, as of the close of business on the date on which this Warrant
shall have been surrendered, the completed Exercise Agreement shall have been delivered, and payment shall have been made for
such shares as set forth above. Certificates for the Warrant Shares so purchased, representing the aggregate number of shares
specified in the Exercise Agreement, shall be delivered to the Holder within a reasonable time, not exceeding three (3) business
days, after this Warrant shall have been so exercised. If this Warrant shall have been exercised only in part, then, unless this
Warrant has expired, the Company shall, at its expense, at the time of delivery of such certificates, deliver to the Holder a
new Warrant representing the number of shares with respect to which this Warrant shall not then have been exercised. 

 

    	 	A-1	 

     

    

 

This
Warrant may also be exercised at such time by means of a “cashless exercise” in which the Holder shall be entitled
to receive a certificate for the number of Warrant Shares equal to the quotient obtained by dividing [(A-B) (X)] by (A), where:

 

(A)
= the average VWAP on the thirty (30) Trading Days immediately preceding the date on which Holder elects to exercise this Warrant
by means of a “cashless exercise,” as set forth in the applicable Notice of Exercise;

 

(B)
= the Exercise Price of this Warrant, as adjusted; and 

 

(X)
= the number of Warrant Shares issuable upon exercise of this Warrant in accordance with the terms of this Warrant by means of
a cash exercise rather than a cashless exercise.

 

“VWAP”
means, for any Trading Day, the price determined by the first of the following clauses that applies: (a) if Common Stock is then
traded or quoted on the Trading Market, the daily volume weighted average price of Common Stock for such Trading Day on the Trading
Market; (b) if Common Stock is not then traded or quoted on the Trading Market and if prices for Common Stock are then reported
in the “Pink Sheets” published by Pink Sheets, LLC (or a similar organization or agency succeeding to its functions
of reporting prices), the most recent bid price per share of Common Stock so reported as of such Trading Day; or (c) in all other
cases, the fair market value of a share of Common Stock as of such Trading Day, as determined by an independent appraiser selected
in good faith by the Holder and reasonably acceptable to the Company.

 

“Trading Day”
means, at any time, a day on which the Trading Market is open for the general trading or quotation of securities and Common Stock
is traded or quoted thereon or, if Common Stock is not then traded or quoted on the Trading Market, a business day.

 

    	 	A-2	 

     

    

 

“Trading
Market” means, at any time, the securities exchange, quotation system or over-the-counter trading facility on which Common
Stock is principally traded or quoted at such time.

 

Notwithstanding
anything in this Warrant to the contrary, in no event shall the Holder be entitled to exercise this Warrant, either in whole or
in part, to obtain a number of Warrant Shares that would result in beneficial ownership by the Holder and its affiliates of more
than 4.9% of the outstanding shares of Common Stock. For purposes of the immediately preceding sentence, beneficial ownership shall
be determined in accordance with Section 13(d) of the Securities Exchange Act of 1934, as amended, and Regulation 13D-G thereunder.
Notwithstanding anything to the contrary contained herein, the limitation on exercise of this Warrant set forth herein may not
be amended without (i) the written consent of the Holder and the Company and (ii) the approval of a majority of shareholders of
the Company.

 

2. Period
of Exercise. This Warrant is exercisable at any time or from time to time on or after
July 31, 2018 and before 5:00 p.m., New York, New York time July 31, 2023 (the “Exercise Period”). 

 

3. Certain
Agreements of the Company. The Company hereby covenants and agrees as
follows:

 

(a) Shares
to be Fully Paid. All Warrant Shares will, upon issuance in accordance with the terms of
this Warrant, be validly issued, fully paid, and nonassessable and free from all taxes, liens, and charges with respect to the
issue thereof.

 

(b) Reservation
of Shares. During the Exercise Period, the Company shall at all times have authorized,
and reserved for the purpose of issuance upon exercise of this Warrant, a sufficient number of shares of Common Stock to
provide for the exercise in full of this Warrant.

 

(c) Successors
and Assigns. This Warrant will be binding upon any entity succeeding to the Company by
merger, consolidation, or acquisition of all or substantially all the Company’s assets.

 

4. Antidilution
Provisions. During the Exercise Period, the Exercise Price and the number of Warrant
Shares shall be subject to adjustment from time to time as provided in this Paragraph 4.

 

In
the event that any adjustment of the Exercise Price as required herein results in a fraction of a cent, such Exercise Price shall
be rounded up to the nearest cent.

 

(a) Subdivision
or Combination of Common Stock. If the Company at any time subdivides (by any stock
split, stock dividend, recapitalization, reorganization, reclassification or otherwise) the shares of Common Stock acquirable
hereunder into a greater number of shares, then, after the date of record for effecting such subdivision, the Exercise Price
in effect immediately prior to such subdivision will be proportionately reduced. If the Company at any time combines (by
reverse stock split, recapitalization, reorganization, reclassification or otherwise) the shares of Common Stock acquirable
hereunder into a smaller number of shares, then, after the date of record for effecting such combination, the Exercise Price
in effect immediately prior to such combination will be proportionately increased.

 

    	 	A-3	 

     

    

 

(b) Adjustment
in Number of Warrant Shares. Upon each adjustment of the Exercise Price pursuant to the
provisions of this Paragraph 4, the number of Warrant Shares issuable upon exercise of this Warrant shall be adjusted by
multiplying a number equal to the Exercise Price in effect immediately prior to such adjustment by the number of Warrant
Shares issuable upon exercise of this Warrant immediately prior to such adjustment and dividing the product so obtained by
the adjusted Exercise Price. 

 

(c) Consolidation,
Merger or Sale. In case of any consolidation of the Company with, or merger of the
Company into any other corporation or other entity, or in case of any sale or conveyance of all or substantially all of the
assets of the Company other than in connection with a plan of complete liquidation of the Company, then as a condition of
such consolidation, merger or sale or conveyance, adequate provision will be made whereby the Holder of this Warrant will
have the right to acquire and receive upon exercise of this Warrant in lieu of the shares of Common Stock immediately
theretofore acquirable upon the exercise of this Warrant, such shares of stock, securities or assets as would be issued or
payable with respect to or in exchange for the number of shares of Common Stock immediately theretofore acquirable and
receivable upon exercise of this Warrant in connection with such consolidation, merger or sale or conveyance. In any such
case, the Company will make appropriate provision to insure that the provisions of this Paragraph 4 hereof will thereafter be
applicable as nearly as may be in relation to any shares of stock or securities thereafter deliverable upon the exercise of
this Warrant. The Company will not effect any consolidation, merger or sale or conveyance unless prior to the consummation
thereof, the successor corporation or other entity (if other than the Company) assumes by written instrument the obligations
under this Paragraph 4(c) and the obligations to deliver to the Holder of this Warrant such shares of stock, securities or
assets as, in accordance with the foregoing provisions, the Holder may be entitled to acquire.

 

5. Issue
Tax. The issuance of certificates for Warrant Shares upon the exercise of this Warrant
shall be made without charge to the Holder of this Warrant or such shares for any issuance tax or other costs in respect
thereof, provided that the Company shall not be required to pay any tax which may be payable in respect of any transfer
involved in the issuance and delivery of any certificate in a name other than the Holder of this Warrant.

 

6. No
Rights or Liabilities as a Shareholder. This Warrant shall not entitle the Holder to
any voting rights or other rights as a shareholder of the Company. No provision of this Warrant, in the absence of
affirmative action by the Holder to purchase Warrant Shares, and no mere enumeration herein of the rights or privileges of
the Holder, shall give rise to any liability of such Holder for the Exercise Price or as a shareholder of the Company,
whether such liability is asserted by the Company or by creditors of the Company.

 

    	 	A-4	 

     

    

 

7. Transfer,
Exchange, and Replacement of Warrant.

 

(a) Restriction
on Transfer. This Warrant and the rights granted to the Holder are transferable, in
whole or in part, upon surrender of this Warrant, together with a properly executed assignment in the form attached hereto,
at the office or agency of the Company, provided, however, that any transfer or assignment shall be subject to the conditions
set forth in Paragraph 7(f) hereof and to the applicable provisions of the Securities Purchase Agreement. Until due
presentment for registration of transfer on the books of the Company, the Company may treat the registered Holder as the
owner and Holder for all purposes, and the Company shall not be affected by any notice to the contrary. Notwithstanding the
above, Holder may subdivide this warrant (i.e. transfer it in part) no more than three (3) times without the written consent
of the Company in its sole discretion.

 

(b) Warrant
Exchangeable for Different Denominations. This Warrant is exchangeable, upon the
surrender hereof by the Holder at the office or agency of the Company, for new Warrants of like tenor representing in the
aggregate the right to purchase the number of shares of Common Stock which may be purchased hereunder, each of such new
Warrants to represent the right to purchase such number of shares as shall be designated by the Holder at the time of such
surrender.

 

(c) Replacement
of Warrant. Upon receipt of evidence reasonably satisfactory to the Company of the
loss, theft, destruction, or mutilation of this Warrant and, in the case of any such loss, theft, or destruction, upon
delivery of an indemnity agreement reasonably satisfactory in form and amount to the Company, or, in the case of any such
mutilation, upon surrender and cancellation of this Warrant, the Company, at its expense, will execute and deliver, in lieu
thereof, a new Warrant of like tenor.

 

(d) Cancellation;
Payment of Expenses. Upon the surrender of this Warrant in connection with any
transfer, exchange, or replacement as provided in this Paragraph 7, this Warrant shall be promptly canceled by the Company.
The Company shall pay all taxes (other than securities transfer taxes) and all other expenses (other than legal expenses, if
any, incurred by the Holder or transferees) and charges payable in connection with the preparation, execution, and delivery
of Warrants pursuant to this Paragraph 7.

 

(e) Register.
The Company shall maintain, at its principal executive offices (or such other office or agency of the Company as it may
designate by notice to the Holder), a register for this Warrant, in which the Company shall record the name and address of
the person in whose name this Warrant has been issued, as well as the name and address of each transferee and each prior
owner of this Warrant.

 

(f) Exercise
or Transfer Without Registration. If, at the time of the surrender of this Warrant in connection
with any exercise, transfer, or exchange of this Warrant, this Warrant (or, in the case of any exercise, the Warrant Shares issuable
hereunder), shall not be registered under the Securities Act of 1933, as amended (the “Securities Act”) and
under applicable state securities or blue sky laws, the Company may require, as a condition of allowing such exercise, transfer,
or exchange, (i) that the Holder or transferee of this Warrant, as the case may be, furnish to the Company a written opinion of
counsel, which opinion and counsel are reasonably acceptable to the Company, to the effect that such exercise, transfer, or exchange
may be made without registration under the Securities Act and under applicable state securities or blue sky laws, (ii) that the
Holder or transferee execute and deliver to the Company an investment letter in form and substance acceptable to the Company and
(iii) that the transferee be an “accredited investor” as defined in Rule 501(a) promulgated under the Securities Act;
provided that no such opinion, letter or status as an “accredited investor” shall be required in connection with a
transfer pursuant to Rule 144 under the Securities Act. The first holder of this Warrant, by taking and holding the same, represents
to the Company that such holder is acquiring this Warrant for investment and not with a view to the distribution thereof. In no
event shall the Holder be permitted to assign the Warrant unless provided with express written consent by the Company.

 

    	 	A-5	 

     

    

 

8.
[Intentionally Omitted]

 

9. Notices.
All notices, requests, and other communications required or permitted to be given or delivered hereunder to the Holder of
this Warrant shall be in writing, and shall be personally delivered, or shall be sent by certified or registered mail or by
recognized overnight mail courier, postage prepaid and addressed, to such holder at the address shown for such holder on the
books of the Company, or at such other address as shall have been furnished to the Company by notice from such holder. All
notices, requests, and other communications required or permitted to be given or delivered hereunder to the Company shall be
in writing, and shall be personally delivered, or shall be sent by certified or registered mail or by recognized overnight
mail courier, postage prepaid and addressed, to the office of the Company at the address set forth in the Securities Purchase
Agreement, or at such other address as shall have been furnished to the Holder of this Warrant by notice from the Company.
Any such notice, request, or other communication may be sent by facsimile, but shall in such case be subsequently confirmed
by a writing personally delivered or sent by certified or registered mail or by recognized overnight mail courier as provided
above. All notices, requests, and other communications shall be deemed to have been given either at the time of the receipt
thereof by the person entitled to receive such notice at the address of such person for purposes of this Paragraph 9, or, if
mailed by registered or certified mail or with a recognized overnight mail courier upon deposit with the United States Post
Office or such overnight mail courier, if postage is prepaid and the mailing is properly addressed, as the case may
be.

 

10. Governing
Law. THIS WARRANT SHALL BE ENFORCED, GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH THE LAWS
OF THE STATE OF DELAWARE APPLICABLE TO AGREEMENTS MADE AND TO BE PERFORMED ENTIRELY WITHIN SUCH STATE, WITHOUT REGARD TO THE PRINCIPLES
OF CONFLICT OF LAWS. THE PARTIES HERETO HEREBY SUBMIT TO THE EXCLUSIVE JURISDICTION OF THE UNITED STATES FEDERAL COURTS LOCATED
IN NEW YORK, NEW YORK WITH RESPECT TO ANY DISPUTE ARISING UNDER THIS WARRANT, THE AGREEMENTS ENTERED INTO IN CONNECTION HEREWITH
OR THE TRANSACTIONS CONTEMPLATED HEREBY OR THEREBY. BOTH PARTIES IRREVOCABLY WAIVE THE DEFENSE OF AN INCONVENIENT FORUM TO THE
MAINTENANCE OF SUCH SUIT OR PROCEEDING. BOTH PARTIES FURTHER AGREE THAT SERVICE OF PROCESS UPON A PARTY MAILED BY FIRST CLASS
MAIL SHALL BE DEEMED IN EVERY RESPECT EFFECTIVE SERVICE OF PROCESS UPON THE PARTY IN ANY SUCH SUIT OR PROCEEDING. NOTHING HEREIN
SHALL AFFECT EITHER PARTY’S RIGHT TO SERVE PROCESS IN ANY OTHER MANNER PERMITTED BY LAW. BOTH PARTIES AGREE THAT A FINAL
NON-APPEALABLE JUDGMENT IN ANY SUCH SUIT OR PROCEEDING SHALL BE CONCLUSIVE AND MAY BE ENFORCED IN OTHER JURISDICTIONS BY SUIT
ON SUCH JUDGMENT OR IN ANY OTHER LAWFUL MANNER. THE PARTY WHICH DOES NOT PREVAIL IN ANY DISPUTE ARISING UNDER THIS WARRANT SHALL
BE RESPONSIBLE FOR ALL FEES AND EXPENSES, INCLUDING ATTORNEYS’ FEES, INCURRED BY THE PREVAILING PARTY IN CONNECTION WITH
SUCH DISPUTE.

 

    	 	A-6	 

     

    

 

11. Miscellaneous.

 

(a) Amendments;
Waivers. No purported amendment to any provision of this Warrant shall be binding on
the parties unless each party has duly executed and delivered to the other party a written instrument which states that it
constitutes an amendment to this Warrant and specifies the provision(s) hereof that are being amended. No purported waiver of
any provision of this Warrant shall be binding on any party unless it has duly executed and delivered to the other party a
written instrument which states that it constitutes a waiver of one or more provisions of this Warrant and specifies the
provision(s) hereof that are being waived. Any such waiver shall be effective only to the extent specifically set forth in
such written instrument. No waiver of any right, power or remedy of a party shall be deemed to be a waiver of any other
right, power or remedy of such party or shall, except to the extent so waived, impair, limit or restrict the exercise of such
right, power or remedy.

 

(b) Descriptive
Headings. The descriptive headings of the several paragraphs of this Warrant are
inserted for purposes of reference only, and shall not affect the meaning or construction of any of the provisions
hereof.

 

(c) Remedies.
The Company acknowledges that a breach by it of its obligations hereunder will cause irreparable harm to the Holder, by
vitiating the intent and purpose of the transaction contemplated hereby. Accordingly, the Company acknowledges that the
remedy at law for a breach of its obligations under this Warrant will be inadequate and agrees, in the event of a breach or
threatened breach by the Company of the provisions of this Warrant, that the Holder shall be entitled, in addition to all
other available remedies at law or in equity, and in addition to the penalties assessable herein, to an injunction or
injunctions restraining, preventing or curing any breach of this Warrant and to enforce specifically the terms and provisions
thereof, without the necessity of showing economic loss and without any bond or other security being required.

 

[REMAINDER
OF PAGE INTENTIONALLY LEFT BLANK]

 

    	 	A-7	 

     

    

 

IN WITNESS WHEREOF,
the Company has caused this Warrant to be signed by its duly authorized officer.

 

	 	ADIAL PHARMACEUTICALS, INC.
	 	 	 
	 	By:	 
	 	 	Name: William B. Stilley
	 	 	Title:   Chief Executive Officer
	 	 	 
	 	 	Dated as of __________, 201[  ]

 

     

     

    

 

FORM OF EXERCISE AGREEMENT

 

Dated:
________ __, 20__

 

		To:	______________________

 

The undersigned,
pursuant to the provisions set forth in the within Warrant, hereby agrees to purchase ________ shares of Common Stock covered by
such Warrant. The undersigned intends that payment of the Exercise Price shall be made as (check one):

 

____
“cash exercise” in the amount of $_________

 

____
“cashless exercise” pursuant to Section 1 of the Warrant.

 

Please
issue a certificate or certificates for such shares of Common Stock in the name of and pay any cash for any fractional share to:

 

	 	Name: ______________________________
	 	 
	 	Signature:______________________________
	 	 
	 	Address:____________________________
	 	 
	 	_____________________________

 

Note:The
above signature should correspond exactly with the name on the face of the within Warrant, if applicable.

 

     

     

    

 

FORM OF ASSIGNMENT

 

FOR VALUE RECEIVED,
the undersigned hereby sells, assigns, and transfers all the rights of the undersigned under the within Warrant, with respect to
the number of shares of Common Stock covered thereby set forth hereinbelow, to:

 

	Name of Assignee	 	Address	 	No of Shares

 

 

 

, and
hereby irrevocably constitutes and appoints ___________________________________ as agent and attorney-in-fact to transfer said
Warrant on the books of Adial Pharmaceuticals, Inc., a Delaware corporation, with full power of substitution in the premises.

 

Dated:________
__, 20__

 

	In the presence of:	 ______________________________
	 	 
	 	Name:______________________________
	 	 
	 	Signature:_________________________
	 	 
	 	Title of Signing Officer or Agent (if any):
	 	 
	 	______________________________
	 	 
	 	Address:

______________________________
	 	 
	 	______________________________

 

Note:
The above signature should correspond exactly with the name on the face of the within Warrant, if applicable.

 

     

     

    

 

Exhibit B

 

FORM OF EXERCISE AGREEMENT

 

Dated:
________ __, 20__

 

		To:	______________________

 

The undersigned, pursuant to the provisions
set forth in the within Warrant, hereby agrees to purchase ________ Units covered by such Warrant. The undersigned intends that
payment of the Exercise Price shall be made as (check one):

 

____ “cash exercise” in the
amount of $_________

 

____ “cashless exercise” pursuant
to Section 1 of the Warrant.

 

Please issue the Units
purchased on the date hereof as follows: (1) a certificate or certificates for _________ shares of Common Stock, and (2) a Common
Warrant to purchase _______ shares of Common Stock to:

 

	 	Name: ______________________________
	 	 
	 	Signature:___________________________
	 	 
	 	Address:____________________________
	 	 
	 	_____________________________

 

Note:
The above signature should correspond exactly with the name on the face of the within Warrant being exercised, if
applicable.

 

    	 	B-1	 

     

    

 

Exhibit C

 

FORM OF ASSIGNMENT

 

FOR
VALUE RECEIVED, the undersigned hereby sells, assigns, and transfers all the rights of the undersigned under the within Warrant,
with respect to the number of Units covered thereby set forth hereinbelow, to:

 

	Name of Assignee	 	Address	 	No. of Units

 

 

 

, and
hereby irrevocably constitutes and appoints ___________________________________ as agent and attorney-in-fact to transfer said
Warrant on the books of Adial Pharmaceuticals, Inc., a Delaware corporation, with full power of substitution in the premises.

 

Dated:________
__, 20__

 

	In the presence of:	______________________________
	 	 
	 	Name: ______________________________
	 	 
	 	Signature: _________________________
	 	 
	 	Title of Signing Officer or Agent (if any):
	 	 
	 	 ______________________________
	 	 
		Address: ______________________________
	 	 
	 	 ______________________________

 

Note:The
above signature should correspond exactly with the name on the face of the within Warrant, if applicable.

 

    	 	C-1Exhibit 4.5

 

NEITHER THIS WARRANT, NOR THE SECURITIES ISSUABLE UPON EXERCISE OF THIS WARRANT (COLLECTIVELY, THE “SECURITIES”), HAVE BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), OR UNDER ANY STATE SECURITIES OR BLUE SKY LAWS. THE SECURITIES ARE SUBJECT TO RESTRICTIONS ON TRANSFERABILITY AND RESALE AND MAY NOT BE OFFERED, SOLD, PLEDGED, HYPOTHECATED OR OTHERWISE TRANSFERRED EXCEPT AS PERMITTED UNDER THE SECURITIES ACT AND APPLICABLE STATE SECURITIES OR BLUE SKY LAWS, PURSUANT TO REGISTRATION OR QUALIFICATION OR EXEMPTION THEREFROM. INVESTORS SHOULD BE AWARE THAT THEY MAY BE REQUIRED TO BEAR THE FINANCIAL RISKS OF THIS INVESTMENT FOR AN INDEFINITE PERIOD OF TIME. THE ISSUER OF THE SECURITIES MAY REQUIRE AN OPINION OF COUNSEL IN FORM AND SUBSTANCE REASONABLY SATISFACTORY TO THE ISSUER TO THE EFFECT THAT ANY PROPOSED TRANSFER IS IN COMPLIANCE WITH THE SECURITIES ACT AND ANY APPLICABLE STATE SECURITIES OR BLUE SKY LAWS.

 

THE SECURITIES ARE SUBJECT TO AND HAVE NOT RECEIVED APPROVAL FROM EITHER THE BERMUDA MONETARY AUTHORITY OR THE REGISTRAR OF COMPANIES IN BERMUDA AND NO STATEMENT TO THE CONTRARY, EXPLICIT OR IMPLICIT IS AUTHORISED TO BE MADE IN THIS REGARD.  THE SECURITIES MAY BE OFFERED OR SOLD IN BERMUDA ONLY IN COMPLIANCE WITH THE PROVISIONS OF THE INVESTMENT BUSINESS ACT 2003 OF BERMUDA AND THE EXCHANGE CONTROL ACT 1972 OF BERMUDA AND REGULATIONS THEREUNDER.  IN ADDITION TO THE FOREGOING, NON-BERMUDIAN PERSONS MAY NOT CARRY ON OR ENGAGE IN ANY TRADE OR BUSINESS IN BERMUDA UNLESS SUCH PERSONS ARE AUTHORIZED TO DO SO UNDER APPLICABLE BERMUDA LEGISLATION.  ENGAGING IN THE ACTIVITY OF DISTRIBUTING OR MARKETING THIS DOCUMENT IN BERMUDA TO PERSONS IN BERMUDA MAY BE DEEMED TO BE CARRYING ON BUSINESS IN BERMUDA.

 

SIRIUS INTERNATIONAL INSURANCE GROUP, LTD.

 

WARRANT

 

	
Warrant   No. 2018-[·]
    	
Date of Issuance: [·], 2018
    

 

Sirius International Insurance Group, Ltd., a Bermuda exempted company (the “Company”), hereby certifies that, for value received, [·], or its registered assign (the “Holder”), is entitled to purchase from the Company [·] common shares (subject to Section 4(b) and Section 4(c), and as adjusted from time to time as provided in Section 9), par value $0.01 per share (the “Common Shares”), of the Company, at a price per Common Share equal to $[·], subject to adjustment from time to time pursuant to Section 9 (the “Exercise Price”), subject to the following terms and conditions:

 

1. Subscription Agreement. This Warrant is issued by the Company pursuant to that certain Subscription Agreement, dated [·], 2018 (the “Subscription Agreement”), by and between the Company and the Holder and is subject to, and the Company and the Holder shall be bound by, all of the applicable terms, conditions and provisions of the Subscription Agreement.

 

2. Registration of Warrant. The Company shall register this Warrant, upon records to be maintained by the Company for that purpose (the “Warrant Register”), in the name of the record Holder hereof from time to time. The Company may deem and treat the Holder of this Warrant as the absolute owner hereof for the purpose of any exercise hereof or any distribution to the Holder, and for all other purposes, absent actual notice to the contrary.

 

1

 

3. Registration of Transfers. Subject to the Holder’s appropriate compliance with the restrictive legend on this Warrant, the Company shall register the transfer of any portion of this Warrant in the Warrant Register, upon surrender of this Warrant, with the Form of Assignment substantially in the form attached hereto as Attachment B duly completed and signed, to the Company at its address specified herein. Upon any such registration and transfer, a new Warrant to purchase Common Shares, in substantially the form of this Warrant (any such new Warrant, a “New Warrant”), evidencing the portion of this Warrant so transferred shall be issued to the transferee and a New Warrant evidencing the remaining portion of this Warrant not so transferred, if any, shall be issued to the transferring Holder. The acceptance of the New Warrant by the transferee thereof shall be deemed the acceptance by such transferee of all of the rights and obligations of a holder of a Warrant.

 

4. Exercise and Duration of Warrants.

 

(a) This Warrant shall be exercisable by the registered Holder at any time and from time to time after the Date of Issuance set forth above to and including the date that is five (5) years following the Date of Issuance set forth above (the “Expiration Date”). At 5:00 p.m., New York City time, on the Expiration Date, the portion of this Warrant not exercised prior thereto shall be and become void and of no value. The Company may not call or redeem all or any portion of this Warrant without the prior written consent of the Holder.

 

(b) Notwithstanding anything contained herein to the contrary, the Company shall not effect any exercise of this Warrant, and the Holder shall not have the right to exercise any portion of this Warrant, to the extent that, after giving effect to such exercise, the Holder (together with the Holder’s affiliates and any individual, partnership, corporation, limited liability company, joint stock company, unincorporated organization or association, trust, joint venture, association or other similar entity, whether or not a legal entity (each, a “Person”) acting as a group together with the Holder or any of the Holder’s affiliates), would beneficially own in excess of 19.99% of the outstanding Common Shares, unless the Company obtains such approval as may be required by the applicable rules and regulations of the Nasdaq Stock Market (or any national securities exchange on which the Common Shares are then listed) from the shareholders of the Company with respect to the issuance of Common Shares resulting in the beneficial ownership by the Holder (and such Holder’s affiliates and any other Persons acting as a group together with the Holder or any of the Holder’s affiliates) of in excess of 19.99% of the outstanding Common Shares. For purposes of the foregoing sentence, the number of Common Shares beneficially owned by the Holder and its affiliates shall include the number of Common Shares issuable upon exercise of this Warrant with respect to which such determination is being made, but shall exclude the number of Common Shares that would be issuable upon (i) exercise of the remaining, nonexercised portion of this Warrant beneficially owned by the Holder or any of its affiliates and (ii) exercise or conversion of the unexercised or nonconverted portion of any other securities of the Company (including, without limitation, any other securities of the Company or its subsidiaries that would entitle the holder thereof to acquire at any time Common Shares) subject to a limitation on conversion or exercise analogous to the limitation contained herein beneficially owned by the Holder or any of its affiliates.  Except as set forth in the preceding sentence, for purposes of this Section 4(b), beneficial ownership shall be calculated in accordance with Section 13(d) of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), and the rules and regulations promulgated thereunder.  In addition, for purposes of this Section 4(b), “group” has the meaning set forth in Section 13(d) of the Exchange

 

2

 

Act and the rules and regulations promulgated thereunder.  Any determination of whether the limitation contained in this Section 4(b) applies shall be in the sole discretion of the Company.

 

(c) In addition, notwithstanding anything contained herein to the contrary, the Company shall not effect any exercise of this Warrant, and the Holder shall not have the right to exercise any portion of this Warrant, to the extent that such exercise and the resulting issuance of Common Shares requires any regulatory approval or regulatory filing under applicable insurance laws, unless the Holder obtains such approval or makes such regulatory filing prior to any such exercise and issuance.  Any determination of whether the limitation contained in this Section 4(c) applies shall be in the sole discretion of the Company.

 

5. Delivery of Common Shares.

 

(a) To effect exercises hereunder, the Holder shall not be required to physically surrender this Warrant unless the total number of Common Shares (as adjusted from time to time as provided in Section 9) represented by this Warrant is being exercised. Upon delivery of an Exercise Notice substantially in the form attached hereto as Attachment A (an “Exercise Notice”) to the Company at its address for notice determined as set forth herein, and upon payment of the Exercise Price multiplied by the number of Common Shares that the Holder intends to purchase hereunder, the Company shall promptly (but in no event later than five (5) trading days after the Date of Exercise (as defined below)) issue and deliver, or cause its transfer agent to issue and deliver, to the Holder a certificate for the Common Shares issuable upon such exercise, or at the Holder’s option deliver such Common Shares in book entry form, registered in the name of the Holder or its designee. A “Date of Exercise” means the date on which the Holder shall have delivered to the Company: (i) an Exercise Notice, appropriately completed and duly signed, and (ii) payment of the Exercise Price (by certified or official bank check, intra-bank account transfer or wire transfer) for the number of Common Shares so indicated by the Holder to be purchased.

 

(b) If by the fifth (5th) trading day after a Date of Exercise the Company fails to deliver the required number of Common Shares in the manner required pursuant to Section 5(a), the Holder will have the right to rescind such exercise.

 

(c) The Company’s obligations to issue and deliver Common Shares in accordance with the terms hereof are absolute and unconditional, irrespective of any action or inaction by the Holder to enforce the same, any waiver or consent with respect to any provision hereof, the recovery of any judgment against any Person or any action to enforce the same, or any setoff, counterclaim, recoupment, limitation or termination, or any breach or alleged breach by the Holder or any other Person of any obligation to the Company or any violation or alleged violation of law by the Holder or any other Person, and irrespective of any other circumstance that might otherwise limit such obligation of the Company to the Holder in connection with the issuance of Common Shares. Nothing herein shall limit a Holder’s right to pursue any other remedies available to it hereunder, at law or in equity, including a decree of specific performance and/or injunctive relief with respect to the Company’s failure to timely deliver Common Shares upon exercise of this Warrant as required pursuant to the terms hereof.

 

3

 

6. Charges, Taxes and Expenses.

 

(a)                                                Issuance and delivery of certificated or uncertificated Common Shares upon exercise of this Warrant shall be made without charge to the Holder for any issue or transfer tax, transfer agent fee or other incidental tax or expense in respect of the issuance of such shares, all of which taxes and expenses shall be paid by the Company; provided, however, that the Company shall not be required to pay any tax that may be payable in respect of any transfer involved in the registration of any Common Shares or Warrants in a name other than that of the Holder. The Holder shall be responsible for all other tax liability that may arise as a result of holding or transferring this Warrant or receiving Common Shares upon exercise hereof.

 

(b)                                                In the event that the Company or its agent determines that they are obligated to withhold or deduct any tax or other governmental charge under any applicable law on behalf of a Holder, notwithstanding anything else to the contrary herein, the Company or its agent shall be entitled, but not obligated, to deduct and withhold such amount by withholding any property (including, without limitation, Common Shares or cash) that would otherwise be delivered to or is owned by such Holder, in each case in such amounts as is required to meet the withholding obligations, and shall also be entitled, but not obligated, to sell all or a portion of such withheld property by public or private sale in such amounts and in such manner as they deem necessary and practicable to pay such taxes and charges. Any amount or property withheld in accordance with this section shall be treated for all purposes of this Warrant as having been paid to the Holder in respect of which such deduction and withholding was made.

 

7. Replacement of Warrant. If this Warrant is mutilated, lost, stolen or destroyed, the Company shall issue or cause to be issued in exchange and substitution for and upon cancellation hereof, or in lieu of and substitution for this Warrant, a new warrant, but only upon receipt of evidence reasonably satisfactory to the Company of such loss, theft or destruction and customary and reasonable indemnity (which shall not include a surety bond), if requested. Applicants for a new warrant under such circumstances shall also comply with such other reasonable regulations and procedures and pay such other reasonable third-party costs as the Company may prescribe. If a new warrant is requested as a result of a mutilation of this Warrant, then the Holder shall deliver this mutilated Warrant to the Company as a condition precedent to the Company’s obligation to issue the new warrant.

 

8. Reservation of Common Shares. The Company covenants that it will at all times reserve and keep available out of the aggregate of its authorized but unissued and otherwise unreserved Common Shares, solely for the purpose of enabling it to issue Common Shares upon exercise of this Warrant as herein provided, the number of Common Shares that are then issuable and deliverable upon the exercise of this entire Warrant. The Company covenants and warrants that all Common Shares so issuable and deliverable shall, upon issuance and the payment of the applicable Exercise Price in accordance with the terms hereof, be validly issued, fully paid and non-assessable and free and clear of any encumbrances, preemptive rights or restrictions (other than as provided in this Warrant, the Subscription Agreement or any restrictions on transfer generally imposed under applicable securities laws).

 

9. Certain Adjustments and Notices.

 

(a) Stock Dividends and Splits. If the Company shall, at any time or from time to time after the Date of Issuance, (i) pay a dividend or make any other distribution upon the Common Shares payable in Common Shares or any other equity or equity equivalent securities of the

 

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Company or (ii) subdivide (by any share split, recapitalization or otherwise) its outstanding Common Shares into a greater number of shares, then the Exercise Price in effect immediately prior to any such dividend, distribution or subdivision shall be proportionately reduced and the number of Common Shares issuable upon exercise of this Warrant shall be proportionately increased. If the Company at any time combines (by combination, reverse share split or otherwise) its outstanding Common Shares into a smaller number of shares, then the Exercise Price in effect immediately prior to such combination shall be proportionately increased and the number of Common Shares issuable upon exercise of this Warrant shall be proportionately decreased. Any adjustment under this Section 9(a) shall become effective at the close of business on the date the dividend, subdivision or combination becomes effective. The Company may in its sole discretion, but shall not be required to, make such decreases in the Exercise Price, in addition to those required by this Section 9, as the Company considers to be advisable in order to avoid or diminish any income tax to any holders of shares of any class of shares of the Company resulting from any dividend or distribution of shares or issuance of rights or warrants to purchase or subscribe for shares or from any event treated as such for income tax purposes or for any other reason. (b) Fundamental Transaction. In the event of any (i) capital reorganization of the Company, (ii) reclassification of the shares of the Company (other than a change in par value or as a result of a share dividend or subdivision, split-up or combination of shares), (iii) consolidation, amalgamation or merger of the Company with or into another Person, (iv) sale of all or substantially all of the Company’s assets to another Person or (v) other similar transaction (other than any such transaction covered by Section 9(a)) (each, a “Fundamental Transaction”), in each case which entitles the holders of Common Shares to receive (either directly or upon subsequent liquidation) shares, securities or assets with respect to or in exchange for Common Shares, then each Common Share issuable pursuant to this Warrant shall, immediately after such Fundamental Transaction, be exercisable for the kind and number of shares or other securities or assets of the Company or of the successor Person resulting from such Fundamental Transaction to which the Holder would have been entitled upon such Fundamental Transaction if this Warrant had been exercised in full immediately prior to the time of such Fundamental Transaction and acquired the applicable number of Common Shares then issuable hereunder as a result of such exercise; and, in such case, appropriate adjustment shall be made with respect to Holder’s rights under this Warrant to ensure that the provisions of this Section 9 shall thereafter be applicable, as nearly as possible, to the Common Shares issuable under this Warrant in relation to any shares, securities or assets thereafter acquirable upon exercise of this Warrant and issuance of the Common Shares hereunder (including, in the case of any Fundamental Transaction in which the successor or purchasing Person is other than the Company, an immediate adjustment in the Exercise Price to the value per share for the Common Shares reflected by the terms of such Fundamental Transaction, and a corresponding immediate adjustment to the number of Common Shares acquirable upon exercise of this Warrant without regard to any limitations or restrictions on exercise, if the value so reflected is less than the Exercise Price in effect immediately prior to such Fundamental Transaction). The provisions of this Section 9(b) shall similarly apply to successive Fundamental Transactions. The Company shall not effect any such Fundamental Transaction unless, prior to the consummation thereof, the successor Person (if other than the Company) resulting from such Fundamental Transaction, shall assume, by written instrument substantially similar in form and substance to this Warrant, the obligation to deliver to the Holder such shares, securities or assets which, in accordance with the foregoing provisions, such Holders shall be entitled to receive upon exercise of this Warrant.

 

5

 

(c)  Extraordinary Dividends. If the Company shall, at any time or from time to time after the Date of Issuance, pay a dividend or make a distribution in cash, securities or other assets to the holders of the Common Shares on account of such Common Shares (or other shares of the Company for which the Warrant is then exercisable), other than (a) as described in Section 9(a) or (b) Common Cash Dividends (as defined below) (any such non-excluded event being referred to herein as an “Extraordinary Dividend”), then the Exercise Price shall be decreased, effective immediately after the payment of such Extraordinary Dividend, by the amount of cash and/or the fair market value (as determined by the Board of Directors of the Company, in good faith) of any securities or other assets paid on one Common Share in respect of such Extraordinary Dividend. For purposes of this Section 9(c), “Common Cash Dividends” means any cash dividend or cash distribution which, when combined on a per share basis with the per share amounts of all other cash dividends and cash distributions paid on the Common Shares (or other shares of the Company for which the Warrant is then exercisable) during the 365-day period ending on the date of declaration of such dividend or distribution (as adjusted to appropriately reflect any of the events referred to in other subsections of this Section 9 and excluding cash dividends or cash distributions that resulted in an adjustment to the Exercise Price or to the number of Common Shares issuable on exercise of this Warrant) does not exceed $[·] per Common Share (and, for the avoidance of doubt, the Extraordinary Dividend shall be the amount of such excess).

 

(d) Notice of Adjustment. As promptly as reasonably practicable following any adjustment pursuant to Section 9, but in any event not later than thirty (30) days thereafter, the Company shall furnish to each Holder a certificate of an executive officer setting forth in reasonable detail such adjustment and the facts upon which it is based and certifying the calculation thereof.  As promptly as reasonably practicable following the receipt by the Company of a written request by Holder, but in any event not later than 30 days thereafter, the Company shall furnish to the Holder a certificate of an executive officer certifying the Exercise Price then in effect and the number of Common Shares or the amount, if any, of other shares, securities or assets then issuable to such holder upon exercise of this Warrant.

 

(e) Other Notices.  In the event: (i) that the Company shall take a record of the holders of its Common Shares (or other shares or securities at the time issuable upon exercise of this Warrant) for the purpose of entitling or enabling them to receive any dividend or other distribution, to vote at a meeting (or by written consent), to receive any right to subscribe for or purchase any shares of any class or any other securities, or to receive any other security, (ii) of any Fundamental Transaction, or (iii) of the voluntary or involuntary dissolution, liquidation or winding-up of the Company, then, and in each such case, the Company shall send or cause to be sent to each Holder at least thirty (30) days prior to the applicable record date or the applicable expected effective date, as the case may be, for the event, a written notice specifying, as the case may be, (A) the record date for such dividend, distribution, meeting or consent or other right or action, and a description of such dividend, distribution or other right or action to be taken at such meeting or by written consent or (B) the effective date on which such Fundamental Transaction, dissolution, liquidation or winding-up is proposed to take place, and the date, if any is to be fixed, as of which the books of the Company shall close or a record shall be taken with respect to which the holders of record of Common Shares (or such other shares or securities at the time issuable upon exercise of this Warrant) shall be entitled to exchange their Common Shares (or

 

6

 

such other shares or securities) for securities or other property deliverable upon such Fundamental Transaction, dissolution, liquidation or winding-up, and the amount per share and character of such exchange applicable to the Common Shares issuable upon exercise of this Warrant.

 

10. No Fractional Shares. No fractional Common Shares will be issued in connection with any exercise of this Warrant. In lieu of any fractional shares that would otherwise be issuable, the Company shall pay the Holder an amount of cash equal to the product of such fraction multiplied by the closing price of one Common Share as reported on the principal trading market for the Common Shares on the Date of Exercise.

 

11. No Impairment. The Company shall not by any action including, without limitation, amending its certificate of incorporation, any reorganization, transfer of assets, consolidation, merger, amalgamation, dissolution, issue or sale of securities or any other voluntary action, avoid or seek to avoid the observance or performance of any of the terms of this Warrant, but shall at all times in good faith assist in the carrying out of all such terms and in the taking of all such action, as may be necessary or appropriate to protect the rights of the Holder against impairment. Without limiting the generality of the foregoing, the Company shall take all such action as may be necessary or appropriate in order that the Company may validly issue fully paid and non-assessable Common Shares upon the exercise of this Warrant at the then Exercise Price therefor.

 

12. No Rights as a Shareholder; Notice to Holder. Nothing contained in this Warrant shall be construed as conferring upon the Holder the right to vote or to consent or to receive notice as a shareholder in respect of any meeting of shareholders for the election of directors of the Company or any other matter, or any rights whatsoever as a shareholder of the Company.

 

13. Warrant Agent. The Company shall serve as warrant agent under this Warrant. Upon thirty (30) days’ notice to the Holder, the Company may appoint a new warrant agent. Any corporation into which the Company or any new warrant agent may be merged or any corporation resulting from any consolidation to which the Company or any new warrant agent shall be a party or any corporation to which the Company or any new warrant agent transfers substantially all of its corporate trust or shareholders services business shall be a successor warrant agent under this Warrant without any further act. Any such successor warrant agent shall promptly cause notice of its succession as warrant agent to be mailed (by first class mail, postage prepaid) to the Holder at the Holder’s last address as shown on the Warrant Register.

 

14. Miscellaneous.

 

(a) Notices. Any notice or communication required or permitted hereunder (including any Exercise Notice) shall be in writing and either delivered personally, emailed, telecopied, sent by overnight mail via a reputable overnight carrier, or sent by certified or registered mail, postage prepaid, and shall be deemed to be given and received (a) when so delivered personally, (b) upon receipt of an appropriate electronic answerback or confirmation when so delivered by telecopy (to such number specified below or another number or numbers as such person may subsequently designate by notice given hereunder), (c) when sent, with no mail undeliverable or other rejection notice, if sent by email, or (d) five (5) business days after the date of mailing to the address below or to such other address or addresses as such person may hereafter designate by notice given hereunder:

 

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(ii) if to the Holder, to such address appearing on the Warrant Register (which shall initially be the facsimile number and email and street address set forth for the initial Holder in the Subscription Agreement);

 

(ii) if to the Company, to:

 

Sirius International Insurance Group, Ltd.

14 Wesley Street, 5th Floor

Hamilton HM11 Bermuda

Attention: Gene Boxer

Email:            Gene.Boxer@siriusgroup.com

 

with a copy to (which shall not constitute notice to the Company):

 

Sidley Austin LLP

One South Dearborn Street

Chicago, Illinois 60603

Attention:  Sean Keyvan

Email: skeyvan@sidley.com

 

or to such other address, facsimile number or email as the Company or the Holder may provide to the other in accordance with this Section 14(a).

 

(b) Assignment. Subject to the restrictions on transfer described herein, the rights and obligations of the Company and the Holder shall be binding upon, and inure to the benefit of, the successors, assigns, heirs, administrators and transferees of the parties. The Company shall not have the right, directly or indirectly, to assign or transfer this Warrant without the prior written consent of the Holder, which may be withheld in the Holder’s sole discretion, unless as part of a Fundamental Transaction.

 

(c) No Third-Party Beneficiaries. Nothing in this Warrant shall be construed to give to any Person other than the Company and the Holder any legal or equitable right, remedy or cause of action under this Warrant.

 

(d) Amendments; Waiver. This Warrant may be amended only in writing signed by the Company and the Holder. Any provision of this Warrant may be waived, but only if in writing by the party against whom enforcement of any such waiver is sought. No waiver of any default with respect to any provision, condition or requirement of this Warrant shall be deemed to be a continuing waiver in the future or a waiver of any subsequent default or a waiver of any other provision, condition or requirement hereof, nor shall any delay or omission of either party to exercise any right hereunder in any manner impair the exercise of any such right.

 

(e) Governing Law. NOTWITHSTANDING THE PLACE WHERE THIS WARRANT MAY BE EXECUTED OR DELIVERED, THE COMPANY AND THE HOLDER EXPRESSLY AGREE THAT THIS WARRANT SHALL BE GOVERNED BY AND CONSTRUED UNDER THE LAWS OF THE STATE OF NEW YORK AS APPLIED TO AGREEMENTS AMONG NEW YORK RESIDENTS ENTERED INTO AND TO BE PERFORMED ENTIRELY WITHIN NEW YORK, WITHOUT REGARD TO THE

 

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CONFLICT OF LAW PROVISIONS OF SUCH JURISDICTION. Any and all suits, legal actions or proceedings arising out of this Warrant shall be brought in the courts of the State of New York or the United States District Court for the Southern District of New York and the Company and the Holder hereby submit to and accept the exclusive jurisdiction of such courts for the purpose of such suits, legal actions or proceedings. In any such suit, legal action or proceeding, the Company and the Holder waive personal service of any summons, complaint or other process and agree that service thereof may be made by certified or registered mail directed to it pursuant to Section 14(a). To the fullest extent permitted by law, the Company and the Holder hereby irrevocably waive any objection which it may now or hereafter have to the laying of venue or any such suit, legal action or proceeding in any such court and hereby further waive any claim that any such suit, legal action or proceeding brought in any such court has been brought in an inconvenient forum. THE COMPANY AND THE HOLDER (ON BEHALF OF ITSELF AND ITS SUBSIDIARIES) HEREBY KNOWINGLY, INTENTIONALLY AND VOLUNTARILY IRREVOCABLY WAIVE ANY AND ALL RIGHTS TO TRIAL BY JURY IN ANY LEGAL PROCEEDING ARISING OUT OF OR RELATED TO THIS WARRANT OR THE TRANSACTIONS CONTEMPLATED HEREBY.

 

(f) Severability. If one or more provisions of this Warrant are held to be unenforceable under applicable law in any respect, such provision shall be excluded from this Warrant and the balance of this Warrant shall be construed and interpreted as if such provision were so excluded and shall be enforceable in accordance with its remaining terms.

 

* * * * *

 

9

 

IN WITNESS WHEREOF, the Company has caused this Warrant to be duly executed by its authorized officer as of the date first indicated above.

 

 

	
 
    	
SIRIUS INTERNATIONAL   INSURANCE GROUP, LTD.
    
	
 
    	
 
    
	
 
    	
 
    	
 
    
	
 
    	
By:
    	
 
    
	
 
    	
Name:
    
	
 
    	
Title:
    

 

10

 

ATTACHMENT A

 

EXERCISE NOTICE

 

To Sirius International Insurance Group, Ltd.:

 

The undersigned hereby irrevocably elects to purchase common shares of Sirius International Insurance Group, Ltd. pursuant to Warrant No.      , originally issued on [·], 2018 (the “Warrant”). The undersigned elects to utilize the following manner of exercise:

 

Shares:

 

Full Exercise of Warrant

Partial Exercise of Warrant (in the amount of            Shares)

 

Exercise Price: $

 

Manner of Exercise:

 

Certified or Official Bank Check

Intra-Bank Account Transfer

Wire Transfer

 

[Please issue a new warrant for the unexercised portion of the attached Warrant in the name of the [undersigned]/[the undersigned’s nominee as is specified below].]

 

	
Date:
    	
 
    
	
Full Name of Holder*:
    	
 
    
	
Signature of Holder / Authorized Representative:
    	
 
    
	
Name and Title of Authorized Representative†:
    	
 
    
	
Additional Signature of Holder (if jointly held):
    	
 
    
	
Social Security or Tax Identification Number:
    	
 
    
	
Address of Holder:
    	
 
    
	
 
    	
 
    
	
Full Name of Nominee of Holder†:
    	
 
    
	
Address of Nominee of Holder†:
    	
 
    
	
 
    	
 
    

 

*  Must conform in all respects to name of holder as specified on the face of the Warrant.

†  If applicable.

 

Attachment A - 1

 

ATTACHMENT B

 

FORM OF ASSIGNMENT

 

[To be completed and signed only upon transfer of Warrant]

 

FOR VALUE RECEIVED, the undersigned hereby sells, assigns and transfers unto                 the right represented by the attached Warrant to purchase                 Common Shares of Sirius International Insurance Group, Ltd. (the “Company”), to which the Warrant relates and appoints                 as attorney to transfer said right on the books of the Company with full power of substitution in the premises.

 

	
Date:
    	
 
    
	
Full Name of Holder*:
    	
 
    
	
Signature of Holder / Authorized Representative:
    	
 
    
	
Name and Title of Authorized Representative†:
    	
 
    
	
Additional Signature of Holder (if jointly held):
    	
 
    
	
Address of Holder:
    	
 
    
	
 
    	
 
    
	
Full Name of Transferee:
    	
 
    
	
Address of Transferee:
    	
 
    
	
 
    	
 
    
	
In the Presence of:
    	
 
    

 

*  Must conform in all respects to name of holder as specified on the face of the Warrant.

†  If applicable.

 

Attachment B - 1

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