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POLICY NUMBER: 68RPG000O004934600 INTERLINE <br />IL 12 01 11 85 <br />THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. <br />POLICY CHANGES <br />Policy Change <br />Numher 1 <br />POLICY NUMBER <br />POLICY CHANGES EFFECTIVE <br />COMPANY <br />6BRPG0000004934600 <br />05/19/11 <br />Nationwide Mutual Insurance Company <br />NAMED INSURED <br />AUTHORIZED REPRESENTATIVE <br />Maria L Madrigal <br />K&K Insurance Group, Inc. <br />COVERAGE PARTS AFFECTED <br />COMMERCIAL GENERAL LIABILITY COVERAGE <br />CHANGES <br />Forms SRPG8016 and SRPG8018 is added to the policy <br />Ref: CP# 831. <br />The above amendments result in a change of premium as follows: <br />No Change = To be Adjusted at Audit = Additional Premium Return Premium <br />-A� <br />Authorized Representative Signature <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 />