**Effective from:**

**Issued to:**

**Date of Issue: 6/13/57**

(The information provided for above, except the policy number, is required to be stated only when this endorsement is issued for attachment to the policy subsequent to its effective date.)

It is agreed that as of the effective date hereof the policy is amended in the following particulars:

The premium reflecting coverage for Canadian exposures are to be payable through Johnson & Higgins (Canada) Ltd., in Canadian funds.

Indemnification for losses arising out of such exposures are to be payable in Canadian funds.

Premium Split - United States $4,847.90
Canada 152.10

$5,000.00

This endorsement is executed on the reverse side hereof.