# Atlantic County Insurance Company

**Effective:** (At the time stated in the policy), this endorsement forms a part of Policy No.

**Issued to:** [Insured's Name]

**By:** [Insurance Company]

**Endorsement**

(The information provided for 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 UNITED STATES DOLLARS AND CANADIAN DOLLARS AS FOLLOWS:**

- **.968 IN UNITED STATES DOLLARS:** $12,100.00
- **.032 IN CANADIAN DOLLARS:** $400.00
- **100.0:** $12,500.00

All other terms and conditions of the insurance remain unchanged.

**G1000A (12/71)**

**President:** [Signature]
**Authorized Representative:** [Signature]