**POLICY NO:** 8506100  
**EFFECTIVE DATE:**  
**AGENCY NO:**  
**ADD'L PREMIUM:** $  
**RETURN PREMIUM:** $  
**COMPOSITE RATE:**  

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.

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 ACCIDENT, ABOVE $300,000 PER ACCIDENT. $5.00

**PROPERTY DAMAGE LIABILITY:**

* EACH ADDITIONAL $50,000 OR FRACTION THEREOF, PER ACCIDENT, ABOVE $50,000 PER ACCIDENT. $5.00

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

**ADDITIONAL PREMIUM:** B.I. $35.00  
P.D. EXCEPT AUTO - $5.00

**ZURICH INSURANCE COMPANY**  
**AMERICAN GUARANTEE AND LIABILITY INSURANCE COMPANY**

**United States Manager (Zurich)**  
**President (American Guarantee)**

**Countersigned:**  
**Vice President (American Guarantee)**

**Form 116-G**  
**Z 006891**