**Effective from:**

The policy becomes effective on the date specified.

**Amending Policy No.:** EX-3006262

**Issued to:** (Name and address of the insured)

**Date of Issue:** 6-13-67

(The information provided for above, except the policy number, is required to be stated only when this endorsement is issued for attachment to the policy subsequent to its effective date.)

It is agreed that as of the effective date hereof, the policy is amended in the following particulars:

The premiums reflecting coverage for Canadian exposures are to be payable through Johnson & Higgins (Canada) Ltd. in Canadian funds. Indemnification for losses arising out of such exposures are to be payable in Canadian funds.

**Premium Split:**
- United States: $4,847.90
- Canada: 152.10

Total: $5,000.00

This endorsement is executed on the reverse side hereof.