# CHANGE ENDORSEMENT

**TYPE OF COVERAGE:** ☑️ SUPERCOVER-UMBRELLA AND EXCESS LIABILITY
☐ CAPE - Commercial and Personal Excess
☐

**ENDORSEMENT NO.:** 100001
**ENDORSEMENT TITLE:** CANCELLATION - AMENDMENT OF NOTICE

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**IF THE FOLLOWING INFORMATION IS NOT COMPLETE, REFER TO THE APPROPRIATE DECLARATIONS.**

| INSURED | POLICY NUMBER |
|---------|---------------|
| PRODUCER | EFFECTIVE DATE |

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**THE PREMIUM FOR THIS AMENDMENT IS INCLUDED IN THE PREMIUM SHOWN ON THE APPROPRIATE DECLARATIONS UNLESS A SPECIFIC AMOUNT IS SHOWN HERE:**

- ☐ ADDITIONAL PREMIUM $ _______
- ☐ RETURN PREMIUM $ _______

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**AMENDMENT**

THE WORDS "THIRTY (30) DAYS" AS STATED IN B. (1) OF CONDITION 4., CANCELLATION., SHOWN IN THE NEW YORK AMENDATORY - FORM #178241-06-93 NY ARE AMENDED TO READ:

"SIXTY (60) DAYS."

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ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED.

**COUNTERSIGNATURE OF AUTHORIZED AGENT**

[Signature]

**STOCK NO. 175125—9-82**