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POLICY NUMBER: 30 SR1, 703455 <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY_ <br />NOTICE OF CANCELL.F.TION OR NCN-RENSWAL TO <br />DESIGNr.TED PERSON(S1 OR ORG.,NI7_ATlON,Si OTHER <br />THAN THF. N:+MED INSURED- SS1220i^.8i0 <br />IN CONS T_DERAT!ON OF NO CHANGE. TN PREIIT"uM, IT IS HEREBY UNDERSTOOD <br />AND AGREED THAT FORi1 SS12200q!O IS ADDED TO THE POCK' PER THE <br />.TTACHED. <br />Form IH 12 00 11 85 T SEQ. NO. 003 Printed in U.S.A. Page 001 <br />Process Date: )2,'17/12 Expiration Date: OS/04/13 <br />U`7 COF Y <br />