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DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3 <br /> BAP 2177023 3, 281 <br /> f <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 /> °EQLF <br /> _BEF�...:..............._....._...._.. ....................._..............._... .............._.......te1EMBEraInie......................_.,................._.._............_..............._......:.._._.._....._........A13ENT°':�{?FfE!°: <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 /> ITEM THREE- SCHEDULE OF COVERED AUTOS YOU OWN <br /> SYMBOL CA9928 <br /> TYPE CMPCOL COST STATED <br /> VEH ST TER YR DESCRIPTION VEH SERIAL NUMBER AGE NEW CLASS AMT <br /> 010 NC 024 13 DODGE DUMP TD 3C7WRLEL9DG591406 5 55000 21179 <br /> 011 NC 024 08 CHEV PU TO 1GCHK23698F163036 10 50000 01189 <br /> PREMIUMS- MED UN-UD SPEC DEDUCTIBLE <br /> AUTO LIAB PAY MTRST COMP PERIL COLL OTHER COMP COLL PREMIUM <br /> 010 $129. 00 $12 $39 $57 $129 250 500 $366. 00 <br /> 011 $129. 00 $12 $39 $65 $92 250 500 $337 . 00 <br /> DRIVER ID DRIVER NAME <br /> 01 DOUG MALINOWSKI JR <br /> APPLICABLE FORMS <br /> FORM# DATE FORM# DATE FORM# DATE FORM# DATE FORM# DATE <br /> CA-0001 1013 IL-0003 0908 IL-0017 1198 IL-0021 0908 CA-9917 1013 <br /> CA-0126 1013 CA-0199 0189 CA-2384 1013 CA-2394 1013 QRBAP 0716 <br /> CA-2345 1116 CA-9903 1013 CA-2116 1013 CA-2107 1293 <br />