ML-45

Ed. 1/87

CHANGE ENDORSEMENT

The coverage under this endorsement is subject to the terms contained in the General Policy Provisions.

This endorsement forms part of the policy shown below.

Policy No. Our Name

Your Name

Address (as shown on Declarations)

Effective Date of Endorsement Policy Period from to

Agency By

POLICY CHANGES

1. Limit of Liability changes:

	A Residence	B Related Private Structures on the Premises	C Personal Property	D Additional Living Expense & Loss of Rent Coverage	L Personal Liability Each Occurrence	M Medical Payments to Others Each Person
New Limit $
Old Limit $

2. Location and Description Changes: 3. Other Changes (Include Endorsement Numbers and Edition Dates)

PREMIUM ADJUSTMENT

Additional Premium Return Premium

Due at Endorsement Effective Date: $ $

N.Y.S. Fire Premium Fee (if applicable) $ $

REVISED INSTALLMENT PAYMENTS (Applies to three‑year installment policies.)

Dates Due	Original Installments	Increase	Decrease	Revised Installments
	$	$	$	$
	$	$	$	$
Total Premium to Policy Expiration		$	$	$
N.Y.S. Fire Premium Fee (if applicable)		$	$	$