This endorsement forms a part of the designated policy and applies, unless otherwise stated herein, as of the effective time and date of such policy.

**Issued By**

- **Producer's Name and Address**
  - 
  - 
  - 

**Policy No.**
LX 633 11 33

**Effective**
19__ of

**ON ACCOUNT OF THE FOLLOWING THE ADDITIONAL PREMIUM IS $________ RETURN PREMIUM IS $________**

**Endorsement #3**

**CANADIAN DECLARATIONS**

**NAMED INSURED:** INTERNATIONAL BUSINESS MACHINES COMPANY LIMITED (CANADA)

**PRODUCER:** JOHNSON & HIGGINS WILLIS FABER LTD.
PLACE VICTORIA, MONTREAL, CANADA

**PREMIUM:** $311.

**This endorsement shall not be binding upon the company unless countersigned by a duly authorized representative of the __________.**

**Countersigned by** _______________

**LIAB 7251**
C-P