Laserfiche WebLink
HISCOX <br />Policy Number: <br />Named Insured: <br />Endorsement Number: <br />Endorsement Effective: <br />UDC-4766083-CGL-21 <br />Bridgemore dba FBN2020001913 <br />18 <br />May 24, 2021 <br />Hiscox Insurance Company Inc. <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />POLICY CHANGES <br />This endorsement will not be used to decrease coverage, increase rates or deductibles or alter any terms or con- <br />ditions of coverage unless at the sole request of the insured. <br />The following item(s): <br />® <br />Insured's Name <br />❑ <br />Insured's Mailing Address <br />❑ <br />Policy Number <br />❑ <br />Company <br />❑ <br />Effective/Expiration Date <br />❑ <br />Insured's Legal Status/Business of Insured <br />❑ <br />Payment Plan <br />❑ <br />Premium Determination <br />❑ <br />Additional Interested Parties <br />❑ <br />Coverage Forms and Endorsements <br />❑ <br />Limits/Exposures <br />❑ <br />Deductibles <br />❑ <br />Covered Property/Located Description <br />❑ <br />Classification/Class Codes <br />❑ <br />Rates <br />❑ <br />Underlying Insurance <br />is (are) changed to read {See Additional Page(s)): <br />The above amendments result in a change in the premium as follows: <br />NO CHANGES <br />❑ <br />TO BEADJUSTED <br />ADDITIONAL PREMIUM <br />RETURN PREMIUM <br />JIZIJ <br />AT AUDIT <br />t _ Riek Mnu$muntfferieinn <br />CGL E5410 CW (03110) Includes copyrighted material of Insurance Services Office, Inc., °= ReoE o&APPRav®By: <br />with its permission. (i F44* ;t I:. vjt,� <br />Ru k Management Malyst <br />