**ZURICH INSURANCE COMPANY**
**AMERICAN GUARANTEE AND LIABILITY INSURANCE COMPANY**

**POLICY NO:** 8590600  
**EFFECTIVE DATE:** [Not specified]  
**AGENCY NO.:** [Not specified]  
**ADD'L PREMIUM:** $ [Not specified]  
**RETURN PREM:** X

**Named Insured:**

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

**PREMIUM COMPUTATION ENDORSEMENT**

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:** 1,250,000,000  
**COMPOSITE RATES:** .15300  
**EST. PREMIUM:** $191,250.00

**[Signature]**
**[Date]**