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POLICY NUMBER: 6BRPG0000005359200 <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 />6BRPG0000005359200 <br />06/08/13 <br />Nationwide Mutual Insurance Company <br />NAMED INSURED <br />AUTHORIZED REPRESENTATIVE <br />Laverne Davis <br />K&K Insurance Group, Inc. <br />COVERAGE PARTS AFFECTED <br />COMMERCIAL GENERAL LIABILITY COVERAGE <br />CHANGES <br />Forms SRPG8016 and SRPG8018 are added to the policy. <br />Ref: CP# 697 <br />Effective: 06/08/13 to 06/08/14 <br />The above amendments result in a change of premium as follows: <br />No Change 71 To be Adjusted at Audit F-1 Additional Premium 71 Return Premium <br />"•Vi/ <br />Authorized Representative Signature <br />IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 <br />Copyright, ISO Commercial Risk Services, Inc., 1983 <br />C- V As <br />k---� I_V.'�A tlorneY <br />Assis'cant Clty A <br />�,,.�' Page 1 of 1 <br />