**POLICY NO:** 3359700

**EFFECTIVE DATE:** [Not specified]

**WENCY NO:** [Not specified]

**ADD'L PREMIUM:** $ [Not specified]

**RETURN PREMIUM:** $ [Not specified]

**Named Insured:** [Not specified]

**END. #22**

This endorsement is issued by the company named below which is the insurer under the policy designated above issued to the Named Insured and forms a part of said policy as of the effective date hereof, at the hour stated in the policy Declarations.

IT IS AGREED THAT IN ADDITION TO THE PREMIUM OTHERWISE DEVELOPED BY THE POLICY A FIXED BASIC CHARGE PER POLICY (NOT SUBJECT TO DISCOUNT) SHALL BE MADE FOR INCREASED LIMITS OF LIABILITY AS FOLLOWS:

**BODY INJURY LIABILITY:**

EACH ADDITIONAL $100,000 OR FRACTION THEREOF,
PER ACCIDENT, ABOVE $300,000 PER ACCIDENT.
$5.00

**PROPERTY DAMAGE LIABILITY:**

EACH ADDITIONAL $50,000 OR FRACTION THEREOF,
PER ACCIDENT, ABOVE $50,000 PER ACCIDENT.
$5.00

THE ABOVE BASIC CHARGES APPLY FOR ONE YEAR OR LESS AND ARE NOT SUBJECT TO SHORT RATE ADJUSTMENT.

**ADDITIONAL PREMIUM:** B.I. - $35.00
P.D. EXCEPT AUTOS - $5.00

**ZURICH INSURANCE COMPANY**
**AMERICAN GUARANTEE AND LIABILITY INSURANCE COMPANY**

**Counter-signed:** [Signature]
**Date:** [Not specified]

**Form 116-G 1994 42 100 24H**

**United States Manager (Zurich)**
**President American Guaranty**

**Secretary American Guarantor**

**Z 006826**