**POLICY NO:** 8826230  
**EFF DATE OF POL:** 1-1-76  
**EFF DATE OF END:** 1-1-76  
**AGENCY NO:**  
**ADD'L PREMIUM:** $  
**RETURN PREMIUM:** $  

**Named Insured**

This endorsement is issued by that company named below which is the insurer under the policy designated above 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.

**IT IS AGREED THAT:**

IN THE EVENT OF CANCELLATION OR MATERIAL CHANGE IN POLICY COVERAGE, THIRTY (30) DAYS PRIOR WRITTEN NOTICE WILL BE GIVEN BY REGISTERED MAIL FOR THE DEPARTMENT OF LAW OF THE COUNTY OF WESTCHESTER, COUNTY OFFICE BUILDING, WHITE PLAINS, N.Y.

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

**Colostrated...**  
**Authorized sign...**  
**Form 116-6 REV. 94**