**Endorsement**

The information provided above is required to be completed only when this endorsement is issued for attachment to the policy subsequent to its effective date.

IT IS AGREED THAT THE PREMIUM SHOWN IN ITEM 3 OF THE CERTIFICATE IS PAYABLE IN U.S. DOLLARS AND CANADIAN DOLLARS AS FOLLOWS:

- .0615% IN U.S. DOLLARS: $9615.00
- .0385% IN CANADIAN DOLLARS: $385.00
- 100.000%: $10,000.00

All other terms and conditions of this insurance remain unchanged.

**Authorized Representative**