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DocuSign Envelope ID: 167F763C-D16E-41D3-B98F-F5E24EE9CC37 <br /> APM 8231172 4738 <br /> NORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY PART B DECLARATION PAGE <br /> P.O.BOX 27427 RALEIGH,NORTH CAROLINA 27611.7427 PERSONAL AUTO POLICY <br /> AMENDED DECLARATION 01 * * EFFECTIVE 05/16/17 <br /> REASON FOR AMENDMENT SEE DETAILED CHANGES <br /> 4g NUMBEI tgrR4 O M�ER <br /> M B iIP NI ENAGT obg <br /> APM 8231172 04/24/17 10/24/17 1984848 APM DECL 0515 0794227 <br /> AMED ENSUE AND ADDRESPr ....:.',... ...:_ AGEN1 . .:.::... ....... ' r <br /> GARY FALK <br /> MELYNEE FALK <br /> 803 SEVEN OAKS DR JOHN G EDWARDS, LUTCF <br /> GREENSBORO, NC 27410-4656 TELE: (336) 623-1025 <br /> 203 E HARRIS FL <br /> EDEN, NC 27288-5329 <br /> VEHICLES COVERED TYPE SYMBOL STATED <br /> VEH ZIPCD YR MAKE VEH SERIAL NUMBER CMPCOL OCN AMT. CLA SDIP <br /> 001 27410 01 JEEP WRNGLR SAH PP 1J4FA59S71P303580 1616 1B 00 <br /> 002 27410 10 GMC YUKON XL 1 PP 1GKUKKE36AR118016 1515 1A 00 <br /> 003 27410 01 GMC YKNSLE/SLT PP 1GKEK13T61J278879 1212 1A 00 <br /> INSURANCE IS PROVIDED WHERE A PREMIUM IS SHOWN FOR THE COVERAGE. <br /> COVERAGE LIMITS OF LIABILITY PREMIUMS <br /> UNIT 1 2 3 <br /> A BODILY INJURY $300, 000 EA PERSON $500, 000 EA ACC 73. 92 70 . 92 289.92 <br /> A PROPERTY DAMAGE $100, 000 EACH ACCIDENT 54 . 92 51 . 92 190. 92 <br /> B MEDICAL PAYMENTS $2, 000 PER PERSON 6. 00 5. 00 29 .00 <br /> D OTHER THAN COLLISION $0 DEDUCTIBLE 29. 00 26.00 <br /> D COLLISION $500 DEDUCTIBLE 59.00 70.00 <br /> TOWING & LABOR 7 . 00 7.00 <br /> EXTENDED TRANSPORTATION $30/DAY $900 MAX 10 . 00 10 . 00 <br /> RENTED VEHICLE COVERAGE - FULL 2 . 00 <br /> TOTAL BY UNIT 241 . 84 240 .84 509. 84 <br /> C2 UNINS/UNDERINS MTR BI $100, 000 EA PER $300, 000 EA AC $64 . 00 <br /> UNINSURED MOTORIST - PROPERTY DAMAGE $50, 000 $4 . 00 <br /> TOTAL TERM PREMIUM $1, 060.52 <br /> THIS PREMIUM REFLECTS A FARM BUREAU DISCOUNT FOR THE FOLLOWING: <br /> -PREFERRED -MULTICAR POLICY <br /> -PROPERTY COVERAGE WITH FARM BUREAU -FULL PAY PLAN <br /> -PROTECTION PLUS <br /> AIRBAG DISCOUNT APPLIED UNIT 1,2, 3. <br /> IPLBASE R VIEW YOUR POLICY DECLAI TTO AND POL.IC <br /> IFROVSTON C EF 1LL' i CONTACT FOUR tEN`` .L ` YOU 'HAVI AMY <br /> iQUSTTOIS OR CAGED <br /> WE APPRECIATE YOUR BUSINESS. <br />