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FORTRES; <br /> ENDORSEMENT FOR AMENDING NAME AND/OR ADDRESS OF PROTECTED <br /> DENTIST OR PROTECTED ORGANIZATION <br /> Page 1 and Item 1 of the Declarations are amended to change the name and/or address of the protected dentist <br /> or protected organization as follows: <br /> Item 1. Name and Address of the Protected Dentist or Protected Organization: <br /> Rachel Anne Gregg Sigmon, DDS <br /> 3901 North Roxboro Street <br /> Suite 200 <br /> Durham, NC 27704 <br /> As a result of the protected dentist's or protected organization's change in rating territory, the premium <br /> payable under the Policy shall be amended by the following amounts: <br /> Total Additional Premium: $0.00 <br /> In consideration of the additional premium, and the mutual agreements of the protected parties and us, the <br /> Policy identified below, of which this Endorsement is a part, is changed as stated above. <br /> All other terms and conditions of this Policy not specifically changed by this Endorsement shall remain the same. <br /> JMWW W.Asa,AAY <br /> Name <br /> Acwmt Mamger <br /> Title <br /> Signature <br /> Policy Number: 3017314 <br /> Effective: 12:01 A.M., 7/1/2014 <br /> Issued to: Rachel Anne Gregg Sigmon, DDS <br /> FD1008(01/03) Page 1 of 1 Insured Copy <br />