**Automobile Medical Payments**

**Policy No.:** 8359700  
**Effective Date:**  
**Agency No.:**  
**Addl. Premium:**  
**Composite Rate:**  

**Named Insured:**

**It is agreed that the provisions of endorsement form 4075-B apply to this endorsement.**

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.

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

(1) ☐ Any owned automobile  
Estimated Premium $  

(2) ☐ *Any hired automobile  
Estimated Premium $  

(3) ☐ *Any non-owned automobile, if insurance for the use thereof is afforded under Coverage A of the policy  
Estimated Premium $  

(4) ☐ *Any licensed owned private passenger automobile  
Estimated Premium $  
INCL. IN  
COMPOSITE  
RATE  

(5) ☐ *Any automobile designated in the declarations by the letters "M.P."  
Premium $  

(6) ☐ *Any automobile designated in this endorsement  
Premium $  

Year Trade Name Body Motor/Serial No.  

(7) ☐ Any automobile within the Automobile Hazard defined in the Garage endorsement  
Estimated premium $  
* % of Bodily Injury Liability Premium under Garage endorsement.  

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

**Limit of Liability:** $ 2000.00 each person.

**Designated Person if required by Insuring Agreement 2:**

(Continued on reverse side)

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

Countersigned:  
Duly authorized agent

Form 2641.  
Form 842  
100 CAVW with policy series 919, 119, 1317 and 7011  
Z 006827