FORM NUMBERS ATTACHED AT ISSUANCE

G-33461-F(1,2,3,4,5,6,7,8,9,10)

G-40284-E G-40345-B

This endorsement, which forms a part of and is for attachment to the following described policy issued by the company designated therein, takes effect on the effective date of said policy, unless another effective date is shown below, at the hour stated in said policy and expires concurrently with said policy.

| Must Be Completed | Complete Only When This Endorsement Is Not Prepared with the Policy Or Is Not to be Effective with the Policy |
| --- | --- |
| ENDT. NO. | POLICY NO. |
| 1 | RDX 1789014 |
| ISSUED TO | EFFECTIVE DATE OF THIS ENDORSEMENT |

CNA

Countersigned by Authorized Agent

Blank Endorsement
G-33461-F