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DocuSign Envelope ID: 167F763C-D16E-41D3-B98F-F5E24EE9CC37 <br /> APM 8231172 4739 <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 /> FA7 tGY F bfl MBE Htlz O <br /> f.fP NJIyfggfa, ROr .:.. ...T o WN M+4G E <br /> APM 8231172 04/24/17 10/24/17 1984848 APM DECL 0515 0794227 <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 PL <br /> EDEN, NC 27288-5329 <br /> DRIVER ID DRIVER NAME <br /> 01 GARY FALK <br /> 02 MELYNEE FALK <br /> 03 DAVIS BENJAMIN FALK <br /> INEXPERIENCED PRINCIPAL OPERATOR VEHICLE 3 DATE LICENSED 05/16/17 <br /> APPLICABLE FORMS <br /> FORM # DATE UNIT FORM # DATE UNIT FORM # DATE UNIT FORM # DATE UNIT <br /> APMNC 01/10 ALL NC0301 07/87 ALL NC0013 04/16 ALL NC0304 01/98 001 <br /> NC0302 01/99 001 NC0330 01/14 001 NC0304 01/98 002 NC0302 01/99 002 <br /> OTHER POLICIES FOR MEMBERSHIP NUMBER 1984848 : <br /> POLICY INSURED NAME <br /> UP 0056864 GARY FALK <br /> HP 6165421 GARY FALK <br />