**Automobile Medical Payments**

**Policy No:** 8506175  
**Effective Date:**  
**Agency No.:**  
**Addl. Premium:** $ INCL. IN  
**Composite Rate:**  

**Named Insured:**

**Designation of Automobiles For Purposes of Division 1:**

(1) ☐ Any owned automobile  
(2) ☐ *Any hired automobile  
(3) ☐ *Any licensed owned private passenger automobile  
(4) ☐ *Any automobile designated in the declarations by the letters "M.P."  
(5) ☐ *Any automobile designated in this endorsement

- Year  
- Trade Name  
- Body  
- Motor/Serial No.

(6) ☐ Any non-owned automobile, if insurance for the use thereof is afforded under Coverage A of the policy  
(7) ☐ Any automobile within the Automobile Hazard defined in the Garage endorsement  
(8) ☐ Any automobile within the Automobile Hazard defined in the Garage endorsement while being used by the individual named below, subject to the limit of liability specified below with respect to each such named individual.

**Name of Individual:**  
**Limit of Liability each person:** $2,000

*The premium reduction percentage determined in accordance with the premium reduction table does not apply to this insurance.*

**Schedule**

**Designated Person Insured:**  
**Limit of Liability:** $2,000 each person

*(Continued on reverse side)*

**Countersigned by duly authorized agent:**  
**Victor D. Nigo**  
**Attorney in Fact**

**Form 2641-K**

**ZURIC INSURANCE COMPANY**  
**AMERICAN GUARANTEE AND LIABILITY INSURANCE COMPANY**

**Z 006937**