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POLICY NUMBER: 6BMAS0000006030500 <br />INTERLINE <br />IL 12 01 1185 <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />POLICY CHANGES <br />Policy Change <br />Number 1 <br />POLICY NUMBER <br />POLICY CHANGES EFFECTIVE <br />COMPANY <br />68MAS0000006030500 <br />05/30/2018 <br />Nationwide Mutual Insurance Company <br />NAMED INSURED <br />AUTHORIZED REPRESENTATIVE <br />Lisa Fraser Thistle Academy of Irish Dance <br />K&K Insurance Group, Inc. <br />COVERAGE PARTS AFFECTED <br />COMMON POLICY CONDITIONS and COMMERCIAL GENERAL LIABILITY <br />CHANGES <br />Form Number: SRPG8016 and SRPG8018 <br />�X Add Form F-1 Delete Form F-1 Amend Form as Follows: <br />Cert Policy #745 <br />The above amendments result in a change of premium as follows: <br />F No Change 1-1 To be Adjusted at Audit F1 Additional Premium Return Premium <br />Authorized Representative Signature <br />F,e�J`ex�Ned by <br />Gacn1�. <br />PRGS�� <br />IL 1201 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 <br />Copyright, ISO Commercial Risk Services, Inc., 1983 <br />