Injury ProSuci Liability Liability 0 340 Marine PERSONAL PROPERTY 0 345 Marine Product 1 370 Other Saud LIMED 0 171 That in Ladies 0 350 Motor Vehicle 0 MO Other Personal O 355 Motor Vehicle Property Damage Ptoduct liability Cl 385 Pmpeny Denude 8 360 Other Perscal Product liability Injury

Injury ProSuci Liability Liability 0 340 Marine PERSONAL PROPERTY 0 345 Marine Product 1 370 Other Saud LIMED 0 171 That in Ladies 0 350 Motor Vehicle 0 MO Other Personal O 355 Motor Vehicle Property Damage Ptoduct liability Cl 385 Pmpeny Denude 8 360 Other Perscal Product liability Injury

trait 3 113 Recovery of OimPsYmeal Liebigy 3 371 Troth to Lenin j LABOR SOCIAL SECURITY 3 He Sectiritientowegetem o(Veteiso's Beaefes 3 )50 Motor Vehicle 0 )80 Other Personal 3 710 Fair Labor Suadards 0 $61 WA 0195E0 Enchant 0160 Stockholders' Suits 0 355 Motor Yank Property Damage Act 0861

153 Recovery of Overpayment Liability 0 371 Truth in Lending LABOR SOCIAL SECURITY 0 850Securities/Commodities/ of Veteran's Benefit. 0 350 Motor Vehicle 0 380Other Personal 0 710 Fair Labor Standards 0 $61 WA <B9511) Exchange 0 160Stockholders' Stith 0 35S Motor Vehicle Proven). Damage Act

E ISSUER NORTHEAST ZONE BALLSTON SPA OPERATIONS CENTER 100 STATE FARM PLACE BALLSTON SPA, NY 12020-8000 Applicable with respect to the following Motor Vehicle Year Make 2015 MERCEDES-BENZ ML350 4WD ti latigif.514114:11ErffrkMNighla 11'frgigi htiVlgi ' I I I II 1Priti 4.1 • tit Rd In PLEASE

00 00 I-5 C `3CC O 0 C) Co zm 0 0 32 wm liss:oner of Motor Vehicle SEX. M BK HT t NONE NONE ISSUED 09-02-12 EFTA01364312