**POLICY NO:** 8506100  
**EFFECTIVE DATE:**  
**AGENCY NO:**  
**ADD'L PREMIUM:** $  
**RETURN PREMIUM:** $  

**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.

**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 |
|------------------|-----------------|--------------|
| 856,000,000      | .21273          | $182,100.00  |

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

**Victor P. Nigro**  
**BY: Margaret Kelly**  
**ATTORNEY IN FACT**

**United States Manager (Zurich)**  
**President (American Guarantee)**

**Form 116-G**  
**100 W 1142**  
**100 CPM**

**Z 006893**