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POLICY NUMBER: PLH01 GL00004162 <br /> THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br /> GENERAL CHANGE <br /> This endorsement will not be used to decrease coverage, increase rates or deductible or alter any terms or <br /> conditions of coverage unless at the sole request of the insured, <br /> COVERAGE PART INFORMATION—Coverage parts affected by this change as indicated by ® below <br /> X General Liability <br /> ❑ Commercial Property <br /> [] Commercial Automobile <br /> ❑ Crime <br /> ❑ Inland Marine <br /> ❑ Umbrella/Excess <br /> The following item(s): <br /> ❑ Insured's Name ❑ Company <br /> ❑ Policy Number ❑ Insured's Legal Status/Business of Insured <br /> ❑ Effective/Expiration Date ❑ Premium Determination <br /> Additional Insured ❑ Coverage Forms and Endorsements <br /> ❑ Limits/Exposures ❑ Deductibles <br /> ❑ Covered Property/Location Description ❑ Classifications/Class Codes <br /> ❑ Insured's Mailing Address <br /> is (are) changed to read {See Additional Page(s)): <br /> ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED. <br /> The above change(s) result in a change in the premium as follows: <br /> ❑ NO CHANGES XADDITIONAL: $151.93 ❑ RETURN: <br /> (This premium does not include taxes and surcharges) <br /> fr <br /> Paul NjjFhg1& <br /> President SAIC <br /> Date: 5/21/2025 Countersignature: <br /> Authorized Representative <br /> SP-IL-CW-0007 (08/22) c 2022 SiriusPoint America Insurance Company Page 1 of 2 <br /> All Rights Reservec, Nlay not be permission. <br />