This policy consists of this policy cover, the Policy Declarations and the Policy Form and endorsements listed in that declaration form.

In return for payment of the premium, The Travelers agrees with the Named Insured to provide the insurance afforded by this policy. That insurance will be provided by the company indicated as insuring company in the Declarations by the abbreviation of its name.

The companies listed below (each a stock company) have executed this policy, but it is valid only if countersigned on the Policy Declarations by our authorized representative.

The Travelers Indemnity Company (IND)
The Travelers Indemnity Company of Illinois (TIL)

**Secretary**
**President**
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Note: The signatures are not legible in the image, so they are represented as placeholders.