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MESA UNDERWRITERS SPECIALTY <br />INSURANCE COMPANY <br />Endorsement # 1 <br />Named Insured: Vicente Martinez <br />Policy Number: MPoo04010006031 Effective Date: 10/26/2021 <br />(The above information is required only when this form is added after the policy is issued) <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />In consideration of the additional premium (Fully Earned) of $150.00, it is hereby understood and <br />agreed that the following Additional Insured is added to and made a part of this policy per the <br />attached forms. <br />Surplus Lines Tax: $4.50 <br />Stamping Fee: $0.38 <br />TOTAL: $154.88 <br />tb <br />All other terms and conditions of this policy remain unchanged. <br />MB tb <br />MUS 0101 10006 0412 <br />Authorized Signature <br />-- <br />x•" & aprRwea Br: <br />�.r Rislc Managem nClerical Aide <br />Insured Copy <br />