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DocuSign Envelope ID:92EFA578-CE94-4EDA-BAE5-D7664F2BE88A <br /> M r i-I <br /> NORTH 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 /> e >' r6 - <br /> APM 8388077 08/22/17 02/22/18 2125827 APM DECL 0515 0195880 <br /> MA S. <br /> .....:.._ ......... <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 j1 e- <br /> g ( <br /> PITTSBORO, NC 2 312 <br /> VEHICLES COVERED TYPE SYMBOL STATED <br /> ...........:.... <br /> VEH ZIPCD YR MAKE VEH...SERIAL NUMBER CMP\COL OCN AMT. CLA SDIP <br /> 001 R7312 05 TYTA CAMRY BASE PP 4T1BE32K35U576607 11\11 1B 00 <br /> 002 27312 10 NSSN ROGUE S AW PP JN8AS5MV8AW117183 14\14 1.A 00 <br /> 003 27312 12 TYTA RAV4 PP JTMZF4DV7C5047035 18\18 1B 02 <br /> INSURANCE IS PROVIDED WHERE A PREMIUM IS SHOWN FOR THE COVERAGE . <br /> COVERAGE LIMITS OF LIABILITY PREMIUMS <br /> UNIT 1 2 3 <br /> A BODILY INJURY $ 100 , 000 EA PERSON $300 , 000 EA ACC 83 . 66 78 . 66 83 . 66 <br /> A PROPERTY DAMAGE $50 , 000 EACH ACCIDENT 59 . 66 56 . 66 59 . 66 <br /> D OTHER THAN COLLISION $ 100 DEDUCTIBLE 49 . 00 58 . 00 70 . 00 <br /> D COLLISION 0500 DEDUCTIBLE 134 . 00 155. 00 <br /> TOTAL BY UNIT 192. 32 327 . 32 368. 32 <br /> C2 UNINS/UNDERINS MTR BI $ 100 ,000 EA PER $300 ,000 EA AC $64. 00 <br /> UNINSURED MOTORIST - PROPERTY DAMAGE $50 ,000 $4. 00 <br /> TOTAL TERM PREMIUM $955 . 96 <br /> THIS PREMIUM REFLECTS A FARM BUREAU DISCOUNT FOR THE FOLLOWING: <br /> PREMIER -MULTICAR POLICY <br /> -PROPERTY COVERAGE WITH FARM BUREAU -FULL PAY PLAN <br /> PROTECTION PLUS <br /> DRIVER ID DRIVER NAME <br /> 01 DOROTHY CILENTI <br /> 02 LUCAS GRIFFIN <br /> 03 OLIVIA GRIFFIN <br /> - <br /> ----------------------------------------------------------------------- <br /> PLEASE i�E1ll Yfll POCKY IlCLttATON -Aft <br /> I*fJLII;Yivr <br /> I PQVSI [S IAEFULLY CF)NTCT -YOUR AGENT I YI)U SAVE ANY <br /> !.:::.:.............::::::::. . .::.:: <br /> QUESTIONS 0 CHANGES <br /> �.- <br /> i <br /> ! WE APPRECIATE YOUR BUSINESS. <br /> i <br /> i <br /> rE <br /> ri <br /> r <br /> ,. <br /> r <br />