**Endorsement No. 2**

**Canadian Declarations**

**Named Insured:** INTERNATIONAL BUSINESS MACHINES COMPANY LIMITED (CANADA)

**Producer:** JOHNSON & HIGGINS WILLIS FABER LTD., PLACE VICTORIA, MONTREAL, CANADA

**Premium:** $70.04

**On account of the foregoing, the additional premium is $ , the return premium is $**

**This endorsement shall not be binding upon the company unless countersigned by a duly authorized representative of the company. This endorsement forms a part of the designated policy and applies, unless otherwise stated herein, as of the effective time and date of such policy.**

**Policy No.: LX.1.21.75.13 issued to:**

**BY:**
(Insert Name of Company)

**Effective:**
(Date) 19... at... M.

(Hour and Minute)

**COUNTERSIGNED BY:**
AUTHORIZED REPRESENTATIVE

**BRANCH OFFICE:**
AGENT OR
GENERAL AGENT:
BROKER:

(ADDRESS)