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DocuSign Envelope ID:ODO6ADD8-36E0-405B-96F0-B574A8D290B3 <br /> BAP 2177023 2,707 <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 02/24/17 IF PREMIUM IS NOT PAID. <br /> : .....NLlK1lElEt�...._.........._.._._...._..... ...:.................. .......................AtiEt�HEF�6H►P.Nv..........................._.............._...._............_.................................. <br /> BAP 2177023 02/24/17 08/24/17 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 /> OTHER POLICIES FOR MEMBERSHIP NUMBER 1644652: <br /> POLICY INSURED NAME <br /> WC 0253741 DOUG MALINOWSKI <br /> GL 0483161 DOUG MALINOWSKI <br /> HP 6269018 DOUG MALINOWSKI <br /> AP 8359301 DOUG MALINOWSKI <br /> WHEN THE NUMBER OF VEHICLES IS FIVE OR MORE, FLEET RATES APPLY. <br /> 01/07/17/11f41.4-01...-1--...../. <br /> X/91 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 />