**POLICY NO:** 06-68-700

**EFF DATE OF POL:** (Blank)

**EFF DATE OF END:** (Blank)

**AGENCY NO:** (Blank)

**ADD'L PREMIUM:** $ (Blank)

**RETURN PREMIUM:** $ (Blank)

**COMPOSITE RATE:** (Blank)

**Named Insured**

This endorsement is issued by that 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:

**BODILY INJURY LIABILITY:**

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

**PROPERTY DAMAGE LIABILITY:**

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

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

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

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

Countersigned:
(Blank)

**V.G. Gahre**
**William Bialasiewicz**
**Secretary American Guaranty & Liability Insurance Company**

**Z 007109**