# National Union Fire Insurance Company of Pittsburgh, PA.

**POLICY NO.**

The Company agrees with the insured named below, in consideration of the premium paid and subject to all the terms and conditions set forth below that the insurance afforded by this policy shall follow all the terms and conditions of Policy Number_________________________, issued by including all renewals and rewrites thereof.

**NAMED INSURED:**

**ADDRESS:**

**POLICY PERIOD:**

**COVERAGE:**

**LIMIT OF LIABILITY:**

**PREMIUM:**

**RATE:**

IN WITNESS WHEREOF, the Company has caused this policy to be signed by its President and Secretary at New York, New York and countersigned by a duly authorized representative of the Company.

**Marion E. Sipin**  
**SECRETARY**

**Eric Dickinson Jr.**  
**PRESIDENT**

Countersigned by:  
Authorized Representative

Form 8136  
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