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Wain Landscaping & Lawn Care

landscaping, patio, lawn, snow removal

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Drivers Insurance Questionnaire

Name(Required)
Date Originally Licensed(Required)
Date of Birth(Required)
CDL License(Required)
Please Give Specific Descriptions, Dates, and Other Pertinent Information For Any Of The Questions Answered Below
e.g. heart, diabetes, epilepsy, hearing/sight/limb loss, back condition, or any other medical infirmity?
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. I certify that I have given true and complete answers to the above questions. An incorrect answer, intentional or not, to any questions above may jeopardize coverage. You have my permission to obtain a copy of my motor vehicle driving record for purposes of determining my eligibility for coverage under this policy.
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Copyright © 2023 · Wain Landscaping · (724) 524-1560 · Serving Butler, Cranberry, Gibsonia, North Hills