# National Union Fire Insurance Company of Pittsburgh, PA

**Administrative Offices**
70 Pine Street
New York, N.Y. 10270

**Policy No. 1993601**

The Company agrees with the Insured named below, in consideration of the premium paid and subject to all the terms and conditions set forth below that the insurance afforded by this policy shall follow all the terms and conditions of Policy Number [TBA] issued by [Insuring Company], including all renewals and rewrites thereof:

**Named Insured:**
[Insured's Name]

**Address:**
[Insured's Address]

**Policy Period:**
[Start Date] to [End Date]

**Coverage:**
[Coverage Description]

**Limit of Liability:**
[$X,000,000 Each Occurrence and $Y,000,000 Aggregate where applicable; excess of $Z,000,000 Each Occurrence and $A,000,000 Aggregate where applicable when in form is excess of primary.]

**Premium:**
[$X,000]

**Rate:**
[RAT]

IN WITNESS WHEREOF, the Company has caused this policy to be signed by its President and Secretary at New York, New York and countersigned by a duly authorized representative of the Company.

**Secretary:** [Signature]
**President:** [Signature]

**Countersigned by:** [Authorized Representative]

**Order By:** 33856 (8/81)