Form Dl-123 - Driver License Liability Insurance Certification

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DL-123(10-89) DRIVER LICENSE LIABILITY INSURANCE CERTIFICATION
Insured Driver _________________________________ Date of Birth_______________
Policyholder(s)___________________________________________________________
_______________________________________________________________________
________________________________________________________________________
Insurance Company_______________________________________________________
Policy Number_________________________________Effective Date_______________
Agency Name__________________________________Expiration Date_____________
Agents Signature__________________________________________________________
Date this DL-123 completed_________________________________________________
This form is valid for 30 days after completion by insurance agent.

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