This endorsement modifies such insurance as is afforded by the provisions of the policy relating to the following designated insurance.

- WRAP AROUND EXCESS

In consideration of an additional premium of $2,537.72., the premium installments are increased to $26,250.

**COLLECTION INFORMATION**

- MONEY
- NON-MONEY

| Br | Producer | Policy No. | 75 |
|----|----------|------------|----|
| 395|          |            |    |

| Exp M./Day/Yr | P.-Pt | Comm Rate | Cash | Installment |
|---------------|-------|-----------|------|-------------|
|               |       |           | 2537.72 | 2537.72     |

This endorsement forms a part of and is for attachment to the following described policy issued by the company designated therein, takes effect on the effective date of said policy, unless another effective date is shown below, at the hour stated in said policy and expires concurrently with said policy.

**Must Be Completed**

| ENDT. NO. | POLICY NO. |
|-----------|------------|
| 4         | FSC 5136962 |

**Complete Only When This Endorsement Is Not Prepared with the Policy Or Is Not to be Effective with the Policy**

| ISSUED TO | EFFECTIVE DATE OF THIS ENDORSEMENT |
|-----------|-------------------------------------|
| IBM       | 1-1-81                              |

Columbia Casualty Company
INSURANCE FROM CNA
Blank Endorsement
C-17013-A

Countersigned by
Authorized Agent

COLUMBIA CASUALTY CO.