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DocuSign Envelope ID:897E46E3-FA01-48C0-AD59-05BF8E64A105 <br /> 80518 <br /> CHANGE OF DECLARATIONS ENDORSEMENT- PLEASE READ CAREFULLY <br /> NATIONWIDE INSURANCE 0 OF AMERICA <br /> COLUMBUS, 0H 43215-2220 <br /> Policy Number: ACP BAFB 2264894216 <br /> Policy Effective From 05/07/2017 To 05/07/2018 12:01 A.M. Standard Time <br /> Transaction Effective 08/18/2017 12:01 A.M. Standard Time <br /> Named GONZALEZ PAINTERS & CONTRACTORS INC <br /> Insured: <br /> Mailing 4301 BENNETT MEMORIAL RD Premiu <br /> Address: ADDITIONAL $ 574.00 <br /> DURHAM, NC 27705-2305 <br /> Agency: All About Insurance 32 80518-022 000 <br /> 1289 N FORDHAM BLVD 35 Total: $ 574.00 <br /> STE D1 (919)933-4000 COMMSN COM $ 86.1 0 <br /> CHAPEL HILL NC 27514-6110 COMMSN PER $ 0.00 <br /> 'remium <br /> ADDED VEHICLE 3 $ 574.00 <br /> AUTO NO DESCRIPTION <br /> 23 2015 CHEVROLET SILVERADO 2500 <br /> VIN OCN STATED-AMOUNT <br /> 1 GC2CUEG2FZ530746 <br /> RADIUS USE TERRITORY CLASS <br /> C 0013 0348900 <br /> COVERAGE LIMIT/CODE DEDUCTIBLE PREMIUM <br /> LIABILITY SEE ENDORSEMENT CA9927 364.00 <br /> LIABILITY PD 25,000 NO 316.00 <br /> MED PAY 2,000 114.00 <br /> UM BI SEE ENDORSEMENT CA2107 6 .00 <br /> UM PD 25,000 <br /> COMMISSION PERCENT COMMISSION ADJUSTMENT <br /> 15.00 $86. 10 <br /> II <br /> ** <br /> THIS IS NOT A BILL - SEE YOUR BILLING STATEMENT. * * <br /> PH AMEND 1(01-97)00 <br /> DIRECT BILL EC0032 L7F0 2017233 AGENT COPY ACP BAFB2264894216 98150 132 35 0015192 <br />