# GENERAL CHANGE ENDORSEMENT

This endorsement forms a part of and is for attachment to the following designated policy:

- **Affiliated FM Insurance Company**
  - **POLICY NO:** XL 98107
  - **ISSUED TO:**
  - **EFFECTIVE THIS END:**

- **Appalachian Insurance Company**
  - **POLICY NO:** XL 98107
  - **ISSUED TO:**
  - **EFFECTIVE THIS END:**

**Completes Binder No.:** 5

**No Binder:** 5

**Authorized Representative:**

**All Terms and Conditions remain unchanged except:**

- Additional premium due now $ (pro rata of $)
- Return premium due now $ (pro rata of $)
- Premium surcharge audit

It is agreed that such coverage as is afforded by this policy does not apply to any claim or suit for loss or damage arising out of any duty imposed upon the Insured by virtue of the provisions of public law 93-406, The Employee Retirement Income Security Act of 1974.