**AUTOMOBILE MEDICAL PAYMENTS**

**POLICY NO:** 8506100  
**EFFECTIVE DATE:**  
**AGENCY NO:**  
**ADDL. PREMIUM:** $ INCL. IN  
**COMPOSITE RATE:**  

**Named Insured**

**IT IS AGREED THAT THE PROVISIONS OF ENDORSEMENT FORM 4075-1-C APPLY TO THIS ENDORSEMENT**

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.

**Designation of Automobiles For Purposes of Division 1:**

(1) ☐ Any owned automobile  
(2) ☐ *Any hired automobile*  
(3) ☐ *Any licensed owned private passenger automobile*  
(4) ☐ *Any automobile designated in the declarations by the letters "M.P."*  
(5) ☐ *Any automobile designated in this endorsement*  

Year Trade Name Body Motor/Serial No.  

(6) ☐ Any non-owned automobile, if insurance for the use thereof is afforded under Coverage A of the policy  
(7) ☐ Any automobile within the Automobile Hazard defined in the Garage endorsement  
**% of Bodily Injury Liability Premium under Garage endorsement.**  

(8) ☐ Any automobile within the Automobile Hazard defined in the Garage endorsement Premium $ while being used by the individual named below, subject to the limit of liability specified below with respect to each such named individual.  

Name of Individual Limit of Liability each person  

*The premium reduction percentage determined in accordance with the premium reduction table does not apply to this insurance.*

**SCHEDULE**

Designated Person Insured Limit of Liability $ 2,000 each person  

(Continued on reverse side)

Countersigned by duly authorized agent

ZURICH INSURANCE COMPANY  
AMERICAN GUARANTEE AND LIABILITY INSURANCE COMPANY  

Form 2641-K  
Z 006887