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POLICY NUMBER: 6BRPG0000007213900 <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 />Numhwr 9 <br />POLICY NUMBER <br />POLICY CHANGES EFFECTIVE <br />COMPANY <br />6BRPG0000007213900 <br />01/01/20 <br />Nationwide Mutual Insurance Company <br />NAMED INSURED <br />AUTHORIZED REPRESENTATIVE <br />Santiago Bautista <br />K&K Insurance Group, Inc. <br />DBA: Te-Ken'utsu-Kan Karate -Do <br />COVERAGE PARTS AFFECTED <br />Common Policy Conditions <br />CHANGES <br />Form Number: SRPG8016 <br />aAdd Form F-1 Delete Form <br />Amend Form as Follows: <br />Form SRPG8016 has been added to the policy <br />CP# 3 <br />115 <br />Authorized Representative Signature <br />REVIEWED & APPROVED <br />By Ris MANAGEMENT Division <br />3 01010 <br />M. LAMBERT <br />IL 12 01 1185 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 <br />Copyright, ISO Commercial Risk Services, Inc., 1993 <br />