# Document

**Effective**, this endorsement forms a part of Policy No.

(At the time stated in the policy)

**Issued to**

**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.)

**Canadian Broker:**

JOHNSON & HIGGINS WILLIS FABER LTD.
PLACE VICTORIA, SUITE 2300
MONTREAL, QUEBEC H421E2

**Insured's Canadian Address:**

IBM CANADA LTD.
1150 EGLINTON AVENUE EAST
DON MILLS, ONTARIO

All other terms and conditions of this insurance remain unchanged.

**Signature:**
- **President:** [Signature]
- **Authorized Representative:** [Signature]

**IBM-ZRIND 00135**