**THE ST. PAUL INSURANCE COMPANIES**

**ENDORSEMENT #5**

The following spaces preceded by an asterisk (*) need not be completed if this endorsement and the policy have the same inception date.

| ATTACHED TO AND FORMING PART OF POLICY NO. | EFFECTIVE DATE OF ENDORSEMENT | ISSUED TO |
|------------------------------------------|-------------------------------|------------|
| 565XA0492                                |                               |            |

It is understood and agreed that the division of premium is as follows:

- U.S. $969.58
- Canada $30.42

Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions, provisions, agreements or limitations of the above mentioned Policy, other than as above stated.

**Agency Name and Address**

In Witness Whereof, the Company has caused this endorsement to be signed by its President at St. Paul, Minnesota and countersigned by a duly authorized representative of the Company.

**GENERAL**
**By** **R.A.** **President**

14600-4 SEP REV. 8-84  
PRINTED IN U.S.A.