To be attached to and form a part of Policy No. issued to John Doe.

by
THE

INSURANCE COMPANY,

President.

[Street, town and state where office is located.]
INDIVIDUAL

Individual, co-partnership, corporation or estate?

The Policy shall become effective on FEBRUARY 16, 1917, at 12 o'clock midnight standard time at Employer's
address and remain in force until canceled by one of the parties in the manner provided in Condition B of the
Policy. For purposes of premium adjustments and payments and for any other provisions of the Policy having reference
to the Policy Period the entire time during which the Policy shall remain in force shall be divided into Policy Periods.
The first Policy Period shall begin upon the effective date stated above and continue until FEBRUARY 16, 1918,
at the same hour and all subsequent Policy Periods shall automatically become effective at the end of the previous Policy
Period and continue for twelve calendar months thereafter. The estimated advance premium provided below is for the
first Policy Period only. An estimated advance premium shall be due and payable at the beginning of each subsequent
Policy Period, the amount of which shall be the same as for the last previous Policy Period unless the amount thereof
shall be changed on or before the date upon which it is due by written endorsement attached to the Policy. The Min-
imum Premium provided below is for each Policy Period.

Locations of all Factories, Shops, Yards, Buildings, Premises, or other Workplaces of this Employer by Town or City, with Street and Number 224 ELM AVE., NEW PENBROOK, PA.

The foregoing enumeration and description of employees includes all persons legally employed in the service of this
Employer in connection with the business operations above described to whom remuneration of any nature in considera-
tion of service is paid, allowed or due, except the President, a Vice-President, Secretary, or Treasurer of a Corporation
not personally supervising the manual or mechanical processes covered hereby, whose remuneration is not included.
The foregoing estimates of remuneration are offered for the purpose of computing the advance premium. The Company
shall be permitted to examine the books of this Employer, at any time during any Policy Period, or any extension thereof,
or within one year after cancelation, so far as they relate to the remuneration earned by any employees of this Employer
while the Policy was in force.

There are no elevators upon the premises covered by this Policy, which are located and described as follows:
There are 1 steam boilers upon the premises covered by this Policy, which are located and described as follows:
HORIZONTAL TUBULAR

These boilers are insured in

NOT INSURED.

No corrosive chemicals are used-except as herein stated:

NO EXCEPTIONS

No materials designed to be used as explosives are made, stored, or used on premises-except as herein stated:
NO EXCEPTIONS

This Employer is conducting no similar business operations at any location not herein disclosed-except as herein
stated:

NO EXCEPTIONS

No operations of any nature not herein disclosed are conducted by this Employer or anyone else upon the premises
covered hereby-except as herein stated:

NO EXCEPTIONS

The total remuneration earned by employees of this Employer, in the operations covered hereby, during twelve months
ending DEC. 31, 1916, was $49,675.00.

No similar insurance has been declined or canceled by any company during the past three years-except as herein
stated:

NO EXCEPTIONS

The signature to this proposal is accepted by this Employer as his signature.
(Copy of Signature to Proposal) JOHN DOE.

Per