This endorsement modifies such insurance as is afforded by the provisions of the policy relating to the following:

| POLICY NO | EFFECTIVE DATE | AGENCY NO. | ADD'L PREMIUM | RETURN PREMIUM |
|-----------|----------------|------------|---------------|----------------|
| GA 8596100 |                |            | $             | $              |

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

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 |
|-------------------|-----------------|--------------|
| 1,662,408,000     | .14464          | $240,451.    |
|                   |                 | END. #14     | 50,000.       |
|                   |                 | END. #12     | 11,000.       |
|                   |                 |              | $301,451.     |

ZURICH INSURANCE COMPANY
AMERICAN GUARANTEE AND LIABILITY INSURANCE COMPANY

Countersigned:  
Vic Nigro  
Duly authorized agent  

Form 117 50M 5-68

United States Manager (Zurich)  
President (American Guarantees)  
Secretary (American Guarantees)

Z 007047