**Document Title:**

It is agreed that the premium breakdown for the period from 3/21/80 to 5/21/81 shall be as follows:

- $200,283 U.S. Funds
- $6,717 Canadian Funds

**Date:** 4/4/80

**Endorsement:**

The information provided above is valid and in effect only when this endorsement is issued for one (1) month after policy endorsement in its effective date.

**Signatures:**

- **John J. Schachter** - President
- **James V. G. Longmore** - Authorized Representative