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DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3 <br /> BAP 2177023 3,280 <br /> NORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY PART B DECLARATION PAGE <br /> P.O.BOX 27427 RALEIGH,NORTH CAROLINA 27611-7427 BUSINESS AUTO POLICY <br /> POLICY RENEWAL DECLARATION — COVERAGE WILL <br /> ITEM ONE— EXPIRE ON 08/24/17 IF PREMIUM IS NOT PAID. <br /> iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii::::_:.::::-.::,:::::::E1)}JGY:PERaC7D's:*:5::=.:::::::::::::::::::: _...._:.....:..,..,..:: .. .::::..::,_::_:::.::;:::::..:.::::_.::_.:_,__:s:::-:__:.:_:: :...: ....:::..,,...,.. <br /> :::-::::;; --;::-:::: : : :::::::::::___:i�itEEv�BEF�fiHIF�Nt�......_........_..........................................._...._.....................................:.....AS3ENT::: t� E= <br /> BAP 2177023 08/24/17 02/24/18 1644652 BAP DECL 0515 0685538 <br /> DOUG MALINOWSKI JR <br /> DBA WELLSMONT LANDSCAPING <br /> 1740 JOHNSON RD WILL LAWS II, LUTCF <br /> BURLINGTON, NC 27217-8179 TELE: (919) 732-7430 <br /> 110 MILLSTONE DR <br /> HILLSBOROUGH, NC 27278 <br /> FORM OF NAMED INSUREDS BUSINESS— INDIVIDUAL <br /> ITEM TWO— SCHEDULE OF COVERAGES AND COVERED AUTOS <br /> THIS POLICY PROVIDES ONLY THOSE COVERAGES WHERE A CHARGE IS SHOWN IN THE PREMIUM <br /> COLUMNS BELOW. EACH OF THESE COVERAGES WILL APPLY ONLY TO THOSE AUTOS SHOWN AS <br /> COVERED AUTOS. AUTOS ARE SHOWN AS COVERED AUTOS FOR A PARTICULAR COVERAGE BY <br /> THE ENTRY OF ONE OR MORE OF THE SYMBOLS FROM THE COVERED AUTO SECTION OF THE <br /> BUSINESS AUTO COVERAGE FORM NEXT TO THE NAME OF THE COVERAGE. <br /> COVERAGES COVERED LIMIT— THE MOST WE WILL PAY FOR PREMIUM <br /> AUTOS ANY ONE ACCIDENT OR LOSS <br /> LIABILITY INSURANCE 07 $500, 000 $258.00 <br /> AUTO MED. PAY. INS. 07 $5, 000 EA PERSON $24.00 <br /> UNINS/UNDRINS MTR BI 07 $500, 000 EA PERSON $500, 000 EA ACCIDENT $74 . 00 <br /> UNINSURED MTRST PD $500, 000 PER ACCIDENT $4. 00 <br /> PHYSICAL DAMAGE INS. ACTUAL CASH VALUE OR COST OF REPAIR, <br /> WHICHEVER IS LESS MINUS— DEDUCTIBLE SHOWN <br /> COMPREHENSIVE 07 SEE ITEM THREE FOR DEDUCTIBLE FOR EACH $122 . 00 <br /> COVERED AUTO FOR ALL LOSS EXCEPT FIRE <br /> OR LIGHTNING <br /> COLLISION 07 SEE ITEM THREE FOR DEDUCTIBLE FOR EACH $221 . 00 <br /> COVERED AUTO <br /> TOTAL PREMIUM $703. 00 <br /> PR :-=:;s_ ;::: -......: :'sue: ;, :. _, _' '::v:::::.:;_::v::;.._ :::.. .__._ _ :_.. .. - :�,:_::: .::: :::_,...:: :....: :::-:. : .. <br /> PRf V I ION$::::_.- :REFULLY:: 1 'I`A:-::::_::::::: :: .-::: -::::::::_:::-::::::: :::-:;::::: : ::_..:::_ <br /> ::::: :::::_:::: -.._-----._..._........_._._._..__._fib_....----C'I'._:��bU ,::�i�� �,::,T�.::_���::::� �TE.....�11�Y._.___..._.... <br /> WE APPRECIATE YOUR BUSINESS. <br />