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POLICY NUMBER: 6BRPG0000005895300 <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 />68RPG0000005895300 <br />104/16/17 <br />Nationwide Mutual Insurance Company <br />NAMED INSURED <br />AUTHORIZED REPRESENTATIVE <br />Kevin Christian Noonchester <br />K&KInsurance Group, Inc. <br />DBA: NOTEWORTHY PUPPETS INC <br />COVERAGE PARTS AFFECTED <br />Common Policy Conditions <br />CHANGES <br />Form Number: 8016 <br />❑X Add Form ❑ Delete Form F7 Amend Form as Follows: <br />Cart If 1581 <br />The above amendments result in a change of premium as follows: <br />FT No Change F-1 To be Adjusted at Audit El Additional Premium Return Premium <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 />�¢� Page 1 of 1 <br />