This endorsement modifies such insurance as is afforded by the provisions of the policy relating to the following:

| POLICY NO | EFFECTIVE DATE | AGENCY NO. | ADD'L PREMIUM | RETURN PREMIUM |
|-----------|----------------|------------|---------------|----------------|
| GA 8596100 |                |            | $ INCL. IN    | $              |

**Named Insured**

This endorsement is issued by that company named below which is the insurer under the policy designated above issued to the Named Insured and forms a part of said policy as of the effective date hereof, at the hour stated in the policy Declarations.

IT IS AGREED THAT IN ADDITION TO THE PREMIUM OTHERWISE DEVELOPED BY THE POLICY A FIXED BASIC CHARGE PER POLICY (NOT SUBJECT TO DISCOUNT) SHALL BE MADE FOR INCREASED LIMITS OF LIABILITY AS FOLLOWS:

**BODILY INJURY LIABILITY:**

EACH ADDITIONAL $100,000 OR FRACTION THEREOF, PER OCCURRENCE, ABOVE $300,000 PER OCCURRENCE. $5.

**PROPERTY DAMAGE LIABILITY:**

EACH ADDITIONAL $50,000 OR FRACTION THEREOF, PER OCCURRENCE, ABOVE $50,000 PER OCCURRENCE. $5.

THE ABOVE BASIC CHARGES APPLY FOR ONE YEAR OR LESS AND ARE NOT SUBJECT TO SHORT RATE ADJUSTMENT.

PREMIUM: B.I. $35.
P.D. EXCEPT AUTO - $5.

ZURICH INSURANCE COMPANY
AMERICAN GUARANTEE AND LIABILITY INSURANCE COMPANY

Countersigned: [Signature]
Duly authorized agent

United States Manager (Zurich)
President (American Guarantees)
Secretary (American Guarantees)

Form 117 5DM 5-68
ATTORNEY IN FACT
100 CMM
Z 007034