# Zurich Insurance Company

## Policy Details
- **Policy No.:** 86-68-700
- **Eff. Date of Pol.:** [Not specified]
- **Eff. Date of End.:** [Not specified]
- **Agency No.:** [Not specified]
- **Add'l Premium:** $ [Not specified]
- **Return Premium:** $ [Not specified]

## Named Insured
This endorsement is issued by the 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 women's compensation payroll, the composite rate established for the policy.

### Estimated Annual Payroll
- **$1,991,752,000**

### Composite Rates
- **.14016**

### Estimated Premium
- **$279,164**
- **End. No. 13: $50,000**
- **Total: $329,164**

## Actual
- **$1,912,126,000**

## Zurich Insurance Company
- **American Guarantee and Liability Insurance Company**

## Countersigned
- **[Signature]**
- **[Duly authorized agent]**
- **Form 110-G 50M 10-69 ATTORNEY IN FACT**

## IBM 062385