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POLICY NUMBER: GBRPG0000005627000 <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 />6BRPG0000005527000 <br />06!08114 <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 CG2011. SRPG8016, SRPG8018 are added to the policy. <br />Ref: CP# 1203 <br />Effective: 06/08/14 to 06/08/15 <br />The above amendments result in a change of premium as follows: <br />❑X No Change 1-1 To be Adjusted at Audit F-1 Additional Premium El Return Premium <br />Authorized Representative Signature <br />S TO FM <br />AR <br />apRO D A <br />LISA E. STORCK <br />Assistant�AJ! `t�orney <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 />