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DocuSign Envelope ID: 2FEC7950-846A-4427-8D35-5C288A6B81A1 WAWA CYNTHIA INSURANCE AGENCY <br />(626)810-5556 <br />Nationwide <br />360 Clinic <br />Commercial Insurance Application <br />Quote Number: ACP 3009934033 <br />Driver Schedule <br />Driver 1 <br />Name <br />LOCH NGUYEN <br />Date of Birth <br />XX/XX/1989 <br />Gender <br />Male <br />License State <br />California <br />License Number <br />F79XXXYX <br />License Status <br />Active <br />Driver Status <br />Part -Time Driver <br />Driver 2 <br />Name <br />LINH D NGUYEN <br />Date of Birth <br />XX/XX/1991 <br />Gender <br />Female <br />License State <br />California <br />License Number <br />F32XXXXX <br />License Status <br />Active <br />Driver Status <br />Part -Time Driver <br />Driver 3 <br />Name <br />JASMINE T V U <br />Date of Birth <br />XX/XX11997 <br />Gender <br />Female <br />License State <br />California <br />License Number <br />F79XXXXX <br />License Status <br />Active <br />Driver Status <br />Part -Time Driver <br />Driver 4 <br />Name <br />RAQUEL RAMIREZ <br />Date of Birth <br />XXJ)DU1987 <br />Gender <br />Female <br />License State <br />California <br />License Number <br />D69)0CXXX <br />License Status <br />Active <br />Driver Status <br />Part -Time Driver <br />Effective: 01/18/2021 to 01/18/2022 <br />Motor Vehicle Records (MVRs) will be validated at submit. Any changes to driver information or changes returned From MVR validation can result in <br />premium changes. <br />1100 Locust St., Dept. 1100 Page 8 Des Moines, IA 50391-1100 <br />