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POLICY NUMBER: 6BRPG0000006905300 <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 POLICY CHANGES EFFECTIVE COMPANY <br />6BRPG0000006905300 08/15/19 Nationwide Mutual Insurance Company <br />NAMED INSURED AUTHORIZED REPRESENTATIVE <br />Laverne Davis K&K Insurance Group, Inc. <br />COVERAGE PARTS AFFECTED <br />Common Policy Conditions <br />Form Number: SRPG8016 <br />Add Form F Delete Form <br />CP# 1813 <br />CHANGES <br />i l Amend Form as Follows: <br />Authorized Representative Signature <br />REVIEWED & APPROVED <br />By RISC MANAgFMENT DiviSION <br />S P 0 3 2019 <br />FRANCINE R. VILLAREAL <br />IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 <br />Copyright, ISO Commercial Risk Services, Inc., 1983 <br />