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DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3 <br /> BAP 2177023 3, 283 <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 /> :::::::::::.::::::.-::: °:=::::::< .:; :: =:- ~: _............. -.............,> <br /> M Et�-........_._.:::::..::::::::::: _..:. I�iill;tdJBERBHtf*:N.Cs _-:::::_._.::::_:::::;:::_.-:::.:.-_::::.::.::._::-::.:_:::__:....:__::::::: <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 /> 07/08/17 <br /> /45444■LA ... . <br /> DATE <br /> THESE DECLARATIONS TOGETHER WITH THE BUSINESS AUTO POLICY PROVISIONS AND ENDORSE- <br /> MENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. <br />