**Endorsement #2C**

| Policy No | Effective Date | Agency No | Add'l Premium ($) | Return Premium ($) |
|-----------|---------------|-----------|-------------------|--------------------|
| 6359700   |               |           | $                 | $                  |

**Named Insured**

This endorsement is issued by the 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 THE PREMIUMS INDICATED ARE ESTIMATED AND THAT THEY SHALL BE ADJUSTED IN ACCORDANCE WITH MANUAL RATES AND ARE SUBJECT TO THE ATTACHMENT OF SCHEDULES, ETC. AT A LATER DATE.**

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

**Counter-signed:**

**Form 116-G**