**Endorsement**

| Policy No. | Eff. Date of Pol | Exp. Date of Pol | Eff. Date of End | Agency No. | Add'l Premium $ | Return Premium $ |
|------------|-----------------|-----------------|-----------------|------------|-----------------|-----------------|
| 1234567890 | 1/1/2023        | 12/31/2023      | 1/1/2024        | 00515201   | $                | $                |

**Named Insured:** [Name of Business Name]

**Address (including Zip Code):** [Street Address], [City, State ZIP Code]

This endorsement is issued by the company designated in the Declarations which is the insurer under the above numbered policy issued to the Named Insured and forms a part of said policy as of the effective date hereof, at the hour stated in the policy Declarations.

This endorsement changes such insurance as is afforded by provisions of the policy relating to the following:

**EXTENDED REPORTING PERIOD**

THE EXTENDED REPORTING PERIOD DOES NOT REINSTATE NOR INCREASE THE LIMITS OF LIABILITY APPLICABLE TO ANY CLAIM TO WHICH THIS ENDORSEMENT APPLIES. THE EXTENDED REPORTING PERIOD DOES NOT EXTEND THE POLICY PERIOD NOR CHANGE THE SCOPE OF COVERAGE PROVIDED.

**Countersigned:**

**Authorized Representative:** [Signature]

**U-GL-113-A (7-81 ed)**