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DocuSign Envelope ID: 23B19021- F3AC- 4D83- B621- FD21A11682EC <br />NORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY, INC. <br />FORMS SCHEDULE <br />Policy Number: <br />Effective Date: <br />GL 0483161 <br />02/23/2018 <br />Named Insured: DOUG MALINOWSKI JR <br />Expiration Date: 02/23/2019 <br />Effective Date of Change: 05/16/2018 <br />POLICY FORMS <br />Forms and Endorsements Applying to all Coverage Parts and made part of the policy at time of issue: <br />CLPJNC <br />05 <br />09 <br />COMMERCIAL LINES POLICY JACKET <br />IL0003 <br />09 <br />08 <br />CALCULATION OF PREMIUM <br />IL0017 <br />11 <br />98 <br />COMMON POLICY CONDITIONS <br />IL0269 <br />09 <br />08 <br />NORTH CAROLINA CHANGES - CANCELLATION AND NONRENEWAL <br />GENERAL LIABILITY FORMS <br />Forms and Endorsements Applying to this Coverage Part and made part of the policy at time of issue: <br />CG0001 <br />12 <br />07 <br />COMMERCIAL GENERAL LIABILITY COVERAGE FORM <br />CG0068 <br />05 <br />09 <br />RECORDING & DISTRIB OF MATERIAL OR INFO IN VIOLATION OF LAW EXCL <br />CG0300 <br />01 <br />96 <br />DEDUCTIBLE LIABILITY INSURANCE <br />CG2026 <br />07 <br />04 <br />ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION <br />CG2104 <br />11 <br />85 <br />EXCLUSION - PRODUCTS - COMPLETED OPERATIONS HAZARD <br />CG2107 <br />05 <br />14 <br />EXCL- DISCL - PERS /CONE DATA RELATED LIAB <br />CG2132 <br />05 <br />09 <br />COMMUNICABLE DISEASE EXCLUSION <br />CG2142 <br />12 <br />04 <br />EXCL - EXPLOSION, COLLAPSE AND UNDERGROUND PROPERTY DAMAGE HAZARD <br />CG2144 <br />07 <br />98 <br />LIMITATION OF COVERAGE TO DESIGNATED PREMISES OR PROJECT <br />CG2146 <br />07 <br />98 <br />ABUSE OR MOLESTATION EXCLUSION <br />CG2147 <br />12 <br />07 <br />EMPLOYMENT - RELATED PRACTICES EXCLUSION <br />CG2150 <br />09 <br />89 <br />AMENDMENT OF LIQUOR LIABILITY EXCLUSION <br />CG2155 <br />09 <br />99 <br />TOTAL POLLUTION EXCLUSION WITH A HOSTILE FIRE EXCEPTION <br />CG2160 <br />09 <br />98 <br />EXCLUSION -YEAR 2000 COMPUTER- RELATED & OTHER ELECTRONIC PROBLEMS <br />CG2167 <br />12 <br />04 <br />FUNGI OR BACTERIA EXCLUSION <br />CG2170 <br />01 <br />15 <br />CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM <br />CG2176 <br />01 <br />15 <br />EXCL OF PUNITIVE DAMAGES RELATED TO A CERTIFIED ACT OF TERRORISM <br />CG2186 <br />12 <br />04 <br />EXCLUSION - EXTERIOR INSULATION AND FINISH SYSTEMS <br />CG2196 <br />03 <br />05 <br />SILICA OR SILICA- RELATED DUST EXCLUSION <br />CG2294 <br />10 <br />01 <br />EXCL - DAMAGE TO WORK PERFORMED BY SUBCONTRACTORS ON YOUR BEHALF <br />CG2404 <br />05 <br />09 <br />WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US <br />CG2426 <br />07 <br />04 <br />AMENDMENT OF INSURED CONTRACT DEFINITION <br />FBGL03 <br />06 <br />04 <br />EXCLUSION - LEAD <br />FBGL04 <br />06 <br />12 <br />EARTH MOVEMENT AND SUBSIDENCE EXCLUSION <br />FBGL07 <br />02 <br />06 <br />DESCRIPTION OF TERMS USED AS PREMIUM BASES <br />FBGL08 <br />1.1 <br />08 <br />QUICK REFERENCE COMMERCIAL GENERAL LIABILITY COVERAGE PART <br />FBIL01 <br />01 <br />15 <br />CERTIFIED TERROR LOSS DISCLOSURE OF PREM /FED SHARE OF INS LOSSES <br />IL0021 <br />09 <br />08 <br />NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT {BROAD FORM} <br />CLFS 0409 ADDITIONAL INSURED COPY Page 1 of 1 <br />