**The Atlantic Company**

**Insurance Company**

**ENDORSEMENT**

**Effective** (At the time stated in the policy) **issued to**

**by** Insurance Company

(The information provided for above is required to be completed only when this endorsement is issued for attachment to the policy subsequent to its effective date.)

IT IS HEREBY UNDERSTOOD AND AGREED THAT THE PREMIUM BREAKDOWN IS AS FOLLOWS:

| U.S. | 429,425 | U.S. FUNDS |
|-----|---------|-----------|
| CANADA | 15,575 | U.S. FUNDS |
|       | 445,000 |           |

All other terms and conditions of this insurance remain unchanged.

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**President**  
**Authorized Representative**