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DocuSign Envelope ID:CDCEC775-C81E-44AD-AB72-5C4ADF26C195 <br /> tNORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY PART B DECLARATION PAGE <br /> P.O.BOX 27427 RALEIGH,NORTH CAROLINA 27611-7427 PERSONAL AUTO POLICY <br /> POLICY RENEWAL DECLARATION — COVERAGE WILL <br /> EXPIRE ON 08/22/17 IF PREMIUM IS NOT PAID. <br /> PE7LY P149A <br /> P kL1O'Y.NUNtSE . .:: ora......: .... . .AE1 . .... <br /> APM 8388077 08/22/17 02/22/18 2125827 APM DECL 0515 0195880 <br /> :kVAMVIEk MNSU.RE z ND;APOROPO .:,.:L:. . ... A zi.E IT . <br /> DOROTHY CILENTI <br /> 238 TROUT LILY LN <br /> PITTSBORO, NC 27312-8483 DENISE MARTIN, FSCP <br /> TELE : (919) 542-2142 <br /> PO BOX 1030 <br /> PITTSBORO, NC 27312 <br /> APPLICABLE FORMS <br /> FORM # DATE UNIT FORM # DATE UNIT FORM # DATE UNIT FORM # DATE UNIT <br /> APMNC 01/10 ALL NC0301 07/87 ALL NC0013 04/16 ALL <br /> LOSS PAYEE — UNIT 002 LOSS PAYEE — UNIT 003 <br /> SECU SECU <br /> PO BOX 27528 PO BOX 27528 <br /> RALEIGH , NC 27611-7528 RALEIGH , NC 27611-7528 <br /> DESC: 2010 NSSN ROGUE S AW DESC: 2012 TYTA RAV4 <br /> OTHER POLICIES FOR MEMBERSHIP NUMBER 2125827 : <br /> POLICY INSURED NAME <br /> HP 6294526 DOROTHY CILENTI <br />