**POLICY NO:** 86-68-700  
**EFF DATE OF POL:**  
**EFF DATE OF END:**  
**AGENCY NO.:**  
**ADD'L PREMIUM:** $50,000 INCL.  
**RETURN PREMIUM:**  

**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 THE FOLLOWING PREMIUM FOR THE PERIOD 12/31/70 - 1/1/72 IS COLLECTIBLE UNDER FORM S76, NON-OWNED AUTOMOBILES, CLASS I PERSONS:

$50,000.00

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

Countersigned

Form 115-G (Rev. 1984) **American Family**

END. #13
Z 007118