**POLICY NO:** 86-68-700

**EFF DATE OF POL:** (Blank)

**EFF DATE OF END:** (Blank)

**AGENCY NO:** (Blank)

**ADD'L PREMIUM:** $ (Blank)

**RETURN PREMIUM:** $ (Blank)

**Named Insured**

This endorsement is issued by that company named below which is the insurer under the policy designated above issued to the Named Insured and forms a part of said policy as of the effective date hereof at the hour stated in the policy Declarations.

**PREMIUM COMPUTATION ENDORSEMENT**

FOR THE PERIOD DECEMBER 31, 1970 TO JANUARY 1, 1972, THE PREMIUM FOR SUCH INSURANCE AS IS AFFORDED BY THE POLICY SHALL BE COMPUTED BY APPLYING TO EACH $1,000. OF WORKMEN'S COMPENSATION PAYROLL, THE COMPOSITE RATE ESTABLISHED FOR THE POLICY.

| EST. ANN. PAYROLL | COMPOSITE RATES | EST. PREMIUM |
|------------------|----------------|--------------|
| $1,991,752,000   | .14016         | $ 279,164    |

END. NO. 13 50,000.

$ 329,164.

Archived

ZURICH INSURANCE COMPANY
AMERICAN GUARANTEE AND LIABILITY INSURANCE COMPANY

Countersigned

Form 110-G SOM 10/71

Z 007120