**POLICY NO:** 8448300  
**EFFECTIVE DATE:**  
**AGENCY NO:**  
**ADD'L PREMIUM:** $  
**RETURN PREMIUM:** $  

**Named Insured**

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

IT IS AGREED THAT THE PREMIUMS INDICATED ARE ESTIMATED AND THAT THEY SHALL BE ADJUSTED IN ACCORDANCE WITH MANUAL RATES AND ARE SUBJECT TO THE ATTACHMENT OF SCHEDULE ETC. AT A LATER DATE.

**ZURICH INSURANCE COMPANY**  
**AMERICAN GUARANTEE AND LIABILITY INSURANCE COMPANY**

**Countersigned:**  
**Form 116-G**  
**100 M 10-82**  
**100 DMW**  

**United States Manager (Zurich)**  
**President (American Guarantee)**

**Secretary (American Guarantee)**

**Z 006860**