DL-123 Driver License Liability Insurance Certification PDF Details

This form is valid for 30 days after completion by insurance agent.

Driver: Insured Driver, Date of Birth

Dates: Effective Date, Expiration Date

Agency: Agency Name

Signature: Agent's Signature

Completed: Date this DL-123 Completed

Question	Answer
Form Name	DL-123 Driver License Liability Insurance Certification
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min
Edition	10/98
Other names	DL-123, DL 123, DL123, DL-123 insurance form

How to Fill Out Form DL-123

Form DL-123 at a glance

What it is: DL-123 (10/98) is the Driver License Liability Insurance Certification.

Who signs: Enter the Agent's Signature.

A filled-in Form DL-123 example: an agent completes the certification for a driver

Form DL-123 example filled out, example: an agent completes the certification for a driver — An insurance agent completes the DL-123 for driver Jordan Sample, born 05/14/1985. The policy runs from its Effective Date to its Expiration Date, and Jordan Sample is the only policyholder. Nothing goes in Date this DL-123 Completed in the picture because the agent enters that date by hand on the day the agent completes the form. The picture shows the filled form, and its names and figures are sample values.

How to fill out Form DL-123, box by box

Insured driver and policyholders

Enter the Insured Driver and the Date of Birth.

Enter the Policyholder(s).

Insurance company, policy and agency

Enter the Insurance Company.

Enter the Policy Number and the Effective Date.

Enter the Agency Name and the Expiration Date.

Agent's signature and date completed

Enter the Agent's Signature.

Enter the Date this DL-123 Completed.

This form is valid for 30 days after completion by insurance agent.

Sources

[1] Form DL-123 (10/98), Driver License Liability Insurance Certification, Pennsylvania Department of Transportation (the Official source link on this page).

Form DL-123: Driver License Liability Insurance Certification