Policy Information:
Policy Number -
Insured Name 1  
Insured Name 2  
Address 1
Address 2
City         State Zip
Telephone Number - -

Producer:
NYPIUA Producer Number -
Name 1  
Name 2  
Address 1
Address 2
City         State Zip
Telephone Number - -

Location of Property:
Location #
Address 1
Address 2
City         State Zip

Requested Effective Date / /

ENDORSEMENT

Increase Existing Coverage Amount
          Current Amount of Insurance
          Increase by
          New Amount of Insurance    

Add New Cause(s) of Loss
        Add Extended Coverage only
        Add Extended Coverage and Vandalism & Malicious Mischief

Add Extra Expense
          Amount of Insurance desired

          Indicate Limit
                                35-70-100%
                                40-80-100%
                                100-100-100%