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84/19/17 11:14:16 5742911597 -> 574 234 9330 Carla Huchel <br />M 13001 <br />RENFINA L. DEMARATIaNS (CONTINUED) <br />I'oud Shop Po11cy for J WELDY LLC <br />f>lajlcy NuMber, 94•BS-TO27-9 <br />CMS'-1075 <br />Spailage Ceverage <br />CMP-4.70G <br />t3ask-t)p or Droin <br />(UP•4704 <br />Cov;lndonl Pros Loot of Inaorno <br />CMP-4.703 <br />WHY tnterrupTlGn Leot 410m <br />CMP-4765 <br />Excl Em171 Non -Owned Auto Liao <br />4MP-4fara4 <br />AI Doelgn Paegan 0r;,j <br />170-6007 <br />Inland MA,inej Attach Dec <br />* New Form Atlooho l <br />Sr,HE0l I.E OF ADDITIONAL INTERESTS <br />ffilio + M, Type: Arid! Ins3ura�f^5rac:hr�n II <br />Enclofsorf,crnt-C QMP4,360 <br />Lours NuvnOer: NIA <br />(',jTY Or SOUTH FEND INDIANA <br />OFFICIAI-, C)fEICFRS, CMPLOYEE: <br />ArtnNT$ AW) REPHF,SF,NTATIVRS <br />227 W JE. FFR,;' ?N BLVD <br />s50VTH OCNI) IN 4Gf01183Cr <br />Tnirr, policy Ir isatrod by the gL�to 1=3r+n (=1r8 aura t<a, utAlty GUITIP: fey, <br />pafligiPabriq F'nliny <br />You arm erlfitled V) portluipOW in rr. dlstr€buticin of the oarrring'. of thy, ooinparly ar. &+Wrrnin�,d Iry our Board nt Direotors in <br />accordan sg will, tho C,.xnllany'.v Articlec of lncorpclrelk ii. as arnendini. <br />in WRiiesa Who+rec4. the Stale Far-rn Flrn acid Cx.,v lly Company has caused this policy Iry be signed by ita PrazidPnt and <br />Secrtstcry at [3[[1ffujjanrinytynn�. lllirlas R �/ �j <br />,• ff ((JJ .�i!ki.r�t ///�UUUFFF Pr:+ai�iP/nr. <br />Prepared <br />J L1 N Q 1 s016 01,vpp sthl, Sidle F.wn Nblu0I Avtuim;IAv hiwi p.mx GuillinnyJYJ3 <br />C;Mf'a-4�000 IiiclisiiUS �;71n��ith4sl mgiN�ipl nt II�FU�3nGU $urvir�rs liHicU� inc., yvtds ns prn;xiyri!xr <br />MIOB9 Continued on Wxt Pago. Page 6 of 7 <br />Page 007 <br />