**Endorsement**

The information provided above is required to be completed only when this endorsement is issued for attachment to the policy subsequent to its effective date.

IT IS HEREBY UNDERSTOOD AND AGREED THAT THE PREMIUM BREAKDOWN IS AS FOLLOWS:

211,400. - U.S. FUNDS
7,600. - CANADIAN FUNDS
219,000.

All other terms and conditions of this insurance remain unchanged.

**Authorized Representative**
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This document appears to be an insurance endorsement form with details about premium breakdowns in U.S. and Canadian funds. The signature line indicates it has been authorized by a representative.