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INTERLINE <br />IL 12011185 <br />THIS ENDORSEMENT CHANGES THE POLICY. IPLEASE READ IT CAREFULLY. <br />POLICY CHANGES <br />Policy Change <br />Number <br />POLICY NUMBER <br />POLICY CHANGES EFFECTIVE <br />COMPANY <br />61319PG0000005895300 <br />04/16/17 <br />Nationwide Mutual Insurance Company <br />NAMED INSURED <br />AUTHORIZED REPRESENTATIVE <br />Kevin Christian Noonchester <br />K&K Insurance Group, Inc. <br />DBA: NOTEWORTHY PUPPETS INC <br />COVERAGE PARTS AFFECTED <br />Common Policy Conditions <br />CHANGES <br />Form Number: 8016 <br />F7X Add Form F-1 Delete Form El Amend Form as Follows: <br />Cert # 1581 <br />The above amendments result in a change of premium as follows: <br />FX -1 No Change F-1 To be Adjusted at Audit EJ Additional Premium L ---J Return Premium <br />Authorized Representative Signature <br />CD <br />IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page I of 1 <br />Copyright, ISO Commercial Risk Services, Inc., 1983 <br />