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POLICY NUMBER: 6BRPG0000005155500 <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 2 <br />POLICY NUMBER <br />POLICY CHANGES EFFECTIVE <br />COMPANY <br />6BRPG0000005155500 <br />02/07/12 <br />Nationwide Mutual Insurance Company <br />NAMED INSURED <br />AUTHORIZED REPRESENTATIVE <br />Judith R Ospina <br />K&K Insurance Group, Inc. <br />DBA: Js Dance Studio <br />COVERAGE PARTS AFFECTED <br />COMMERCIAL GENERAL LIABILITY COVERAGE <br />CHANGES <br />Forms SRPG8016 and SRPG8018 is added to the policy <br />Ref: CP# 2243. <br />The above amendments result in a change of premium as follows: <br />❑X No Change ❑ To be Adjusted at Audit ❑ Additional Premium ❑ Return Premium <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 />