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DocuSign Envelope ID: 111 C4FE8- F974- 4B76- BC9A- 67E51D5FD6C4 <br />CHANGE OVERPRINT /CHANGE SLIP POLICY NUMBER: 660- 5F243125 -15 -42 <br />ISSUE DATE: 01/23/2015 <br />RATER: NZ <br />CHANGE EFFECTIVE DATE: 01 -23 -15 <br />EFFECTIVE DATE: 01/01/2015 <br />EXPIRATION DATE: 01 /01/2016 <br />INSURED'S NAME: CSG ADVISORS INC <br />New /Renewal: N <br />Solicitor Code: 7E <br />SAI: 4589V7191 <br />MSI: I <br />Rating Mode: <br />S.B. ACCT. EFF. <br />MO. DATE <br />Special Code: <br />Program Code: IA1 <br />Paymode: 0 <br />Audit Frequency: N <br />Responsibility: I <br />PREMIUM <br />.1500 <br />Watch File: <br />Survey Cade: <br />Reinsurance: f <br />DOWNSTREAM <br />Pro Rata Factor: 0.940 <br />PREMIUM SUMMARY <br />OFFICE: PAYROLL 70A <br />PRODUCER NAME: PAYCHEX INS AGENCY INC SV996 <br />Page 1 of 1 <br />