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Doc Sign Envelope ID: 23B19021- F3AC- 4D83- B621- FD21A11682EC <br />FARM NORTH CAROLINA FAW BUREAU MUTUAL INSURANCE COMPANY, INC. <br />IBUREAU COMMERCIAL GENERAL LIABILITY COVERAGE PART <br />INSURANCE SUPPLEMENTAL DECLARATIONS <br />Policy Number: GL 0483151 Policy Period: From: 02/23/2018 To: 02/23/2019 <br />Effective Date of Change: 05/16/2018 <br />Named Insured: DOUG MALINOWSKI JR <br />LIMITS OF INSURANCE <br />S 2,000,000 <br />s 0 <br />S 1,000,000 <br />S 1,000,000 <br />S 100,000 <br />S 5,000 <br />FORM OF BUSINESS: <br />General Aggregate Limit (Other Than Products - Completed Operations) <br />Products /Completed Operations Aggregate Limit <br />Personal Advertising Injury Limit <br />Each Occurrence Limit <br />Damage to Premises Rented To You Limit <br />Medical Expense Limit (Any One Person) <br />INDIVIDUAL <br />Business Description: LANDSCAPE GARDENING <br />Location of All Premises You Own, Rent or Occupy: Refer to Location Schedule - CLOS if applicable <br />AUDIT PERIOD, ANNUAL UNLESS OTHERWISE STATED. <br />TOTAL PREMIUM FOR THIS COVERAGE PART: <br />FORM(S) AND ENDORSEMENT(S) APPLICABLE TO THIS COVERAGE PART: Refer to Forms Schedule - CLFS <br />CGLD 0712 <br />ADDITIONAL INSURED COPY <br />, <br />1,174.00 <br />Page 1 of 1 <br />Rates <br />Advance Premiums <br />Estimated <br />Premises/ Products/ <br />Premises/ <br />Products/ <br />Premium <br />Operations Completed <br />Operations <br />Completed <br />Classifications <br />Codes <br />Bases <br />Operations <br />Operations <br />WAIVER OF SUBROGATION <br />97047 <br />34.337 <br />34 <br />ADDITIONAL INSUREDS <br />49950 ._ <br />77.259 <br />155 <br />LANDSCAPE GARDENING <br />97047 106,663 <br />C, <br />Ill` "L. <br />9$5 <br />`i::'- <br />PRODUCTS /COMPLETED <br />PAYROLL <br />OPERATIONS ARE <br />SUBJECT TO THE GENERAL <br />AGGREGATE LIMIT <br />TOTAL PREMIUM FOR THIS COVERAGE PART: <br />FORM(S) AND ENDORSEMENT(S) APPLICABLE TO THIS COVERAGE PART: Refer to Forms Schedule - CLFS <br />CGLD 0712 <br />ADDITIONAL INSURED COPY <br />, <br />1,174.00 <br />Page 1 of 1 <br />