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Location #1, Building #1 <br />Equipment Breakdown <br />Location #2, Building #1 <br />f <br />$ <br />TOTAL PREMIUM ADJUSTMENTS <br />PREMIUM DUE AT POLICY CHANGE EFFECTIVE DATE <br />ADDITIONAL RETURN <br />$ 50 $ <br />REMOVAL If Covered Property is removed to a new location that is described on this Policy Change, you may <br />PERMIT extend this insurance to include that Covered Property at each location during the removal. <br />Coverage at each location will apply in the proportion that the value at each location bears to the <br />value of all Covered Property being removed. This permit applies up to 10 days after the effective <br />date of this Policy Change; after that, this insurance does not apply at the previous location. <br />Authorized Representative Signature <br />Page 2 of 2 © Insurance Services Office, Inc., 2009 <br />�oRaN <br />RiskMmWmentDMsian <br />REVIEWED & APPROVED BY. - <br />Risk Management Analyst <br />