Has any lead claim or complaint ever been brought? Yes No Has a lead test ever been performed? Yes No Please explain ALL responses: “YES” Insured’s Signature________________________________________________ Date __________________ Signature ___________________________________________________ Date __________________
Has any lead claim or complaint ever been brought? Yes No Has a lead test ever been performed? Yes No Please explain ALL “YES” responses: Insured’s Signature________________________________________________ Date __________________ Signature ___________________________________________________ Date __________________
MU7992.docx