I understand that the coverage selection or rejection indicated above shall apply on this and all future/Amendments or Subrolo policies until a notice The Travelers in writing of any changes to the policy.

If you sign below, and/or pay any premium, you have evidenced your actual knowledge and understanding of the availability of these benefits and limits as well as the benefits and limits you have selected.

Signature of Named Insured: P.J. Noone
Date: 1/13/92

Agent:
Date: