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POLICY NUMBER: 6BRPG0000007213900 <br />INTERLINE <br />IL 12 01 11 85 <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 />6BRPG0000007213900 <br />01 001120 <br />Nationwide Mutual Insurance Company <br />NAMED INSURED <br />AUTHORIZED REPRESENTATIVE <br />Joseph Pizano <br />K&K Insurance Group, Inc. <br />COVERAGE PARTS AFFECTED <br />Common Policy Conditions <br />CHANGES <br />Form Number: SRPG8016 <br />❑X Add Form Delete Form Amend Form as Follows: <br />The following form SRPG8016 has been added to the policy. <br />CP# 5 <br />FWD VI �o"yu <br />Authorized Representative Signature <br />& APPROVED <br />IGEMEw DIVISION <br />132020 <br />IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 SAMANTHA MPIAMg fi T <br />Copyright, ISO Commercial Risk Services, Inc., 1983 <br />