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 |                |            | $ 50,000. INCL. |                |

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.

**[Signature]**

IT IS AGREED THAT THE FOLLOWING PREMIUM IS COLLECTIBLE UNDER FORM S76, NON-OWNED AUTOMOBILES, CLASS I PERSONS:

$50,000.

ZURICH INSURANCE COMPANY
AMERICAN GUARANTEE AND LIABILITY INSURANCE COMPANY

Countersigned: **[Signature]**  
**[Title]**  
**[Date]**

Form 117 50M 5-68  
ATTORNEY IN FACT  
100 LAW

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

Z 007046