# ENDORSEMENT NO. 3

THE ONLY INSURANCE AFFORDED BY THIS POLICY IS IN ACCORDANCE WITH PROVISIONS OF FORM Y-503 ATTACHED.

On account of the foregoing, the additional premium is $ , the return premium is $ This endorsement shall not be binding upon the company unless countersigned by a duly authorized representative of the company. This endorsement forms a part of the designated policy and applies, unless otherwise stated herein, as of the effective time and of such policy.

**Policy No.** LZ.1634 **issued to** INTERNATIONAL BUSINESS MACHINE CORP., ETAL **BY** THE FIDELITY AND CASUALTY COMPANY OF NEW YORK **Effective** MAY 21, 1961 at 12:01 A.M.

COUNTERSIGNED BY **K. Larkin** AUTHORIZED REPRESENTATIVE

BRANCH OFFICE GENERAL AGENT OR BROKER (ADDRESS)

SOURCE TRANS. CO. CODE ACC. LINE REINS. CO. PAY CODE PREMIUM RATE OF CURRENT CANC EXPOSURE RETURN PREMIUM ORIGINAL RETURN PREMIUM PREMIUM DEFERRED CANC CANC CURRENT 60-74 DEFERRED

V AUD SET STATE CITY LNT LINE KIND CLASS EXPOSURE CURRENT 55-58 59 60-65 56-68 55-58 59 60-65 60-74 31 36 39-40 41-43 44 45-46 47-48 49-50 51-54 ACCTG. PREM. BY COMM. RATE