# GENERAL CHANGE ENDORSEMENT

This endorsement forms a part of and is for attachment to the following designated policy:

- **Affiliated FM Insurance Company**
  - **POLICY NO.:** XL 96794
  - **ISSUED TO:** BV
  - **EFFECTIVE DATE OF THIS ENDORSEMENT:**

- **No Binder**
  - **ENDOT. NO.:** 6
  - **AUTHORIZED REPRESENTATIVE:**

**All Terms and Conditions remain unchanged except:**

- ☐ Additional premium due now $ (pro rata of $)
- ☐ Return premium due now $ (pro rata of $)
- ☐ Premium subject to audit.

**It is agreed that the annual premium is allocated as follows:**

| U.S. | $5,800.00 |
|------|-----------|
| Canadian | $200.00 |
| Total Premium | $6,000.00 |

3239 (5/76) Printed in U.S.A.