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DocuSign Envelope ID: 167F763C-D16E-41D3-B98F-F5E24EE9CC37 <br /> APM 8231172 4740 <br /> rNORTH 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 /> E .Mg#lore .... _ MEMBER HI 1O <br /> ��.iD1�NUMBER �ROtir � _...:::._ ....... ....:... ::............. <br /> APM 8231172 04/24/17 10/24/17 1984848 APM DECL 0515 0794227 <br /> _Id MED INS(l ND, f.... .PR ..... : .... .....' :..:.::..... ACS....... <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 /> I <br /> DETAILED CHANGES: <br /> ADD DRIVER <br /> ADD POINTS OR INEXPERIENCED OPERATOR <br /> X/21 /30/17 <br /> AUT DATE <br /> 1 <br />