EEAG-R
USE OF PRIVATE VEHICLES TO TRANSPORT STUDENTS - EEAG-R
School Year ___________
School _______________________________________ Date ____________________
The School Board requires proof of insurance coverage in force on all private vehicles used for the transportation for all school-sponsored activities. The groups that may be transported include, but are not limited to, students, coaches, sponsors, faculty, and chaperones.
This form is to be completed for each private vehicle used for the transportation of school sponsored groups. It is valid for the school year in which it is filed. If the insurance policy expires or is cancelled during the school year, a new statement must be submitted.
DRIVER INFORMATION:
Driver’s Name _______________________________________ Age ________
Address ____________________________________________ Phone ________
New Hampshire Driver’s License:
Type: ______________________ Number: ____________________________
VEHICLE INFORMATION:
Vehicle Make _________________________ Year __________ Model ____________
Inspection Expiration Date ________________________
License Tag ____________________________________
INSURANCE INFORMATION:
Name of Insured(s) _________________________________
Policy Number ____________________________________
Insurance Company ________________________________
Policy period: From _______________________ To ____________________________
This policy provides the following recommended limits of liability coverage for private passenger cars and qualified multipurpose passenger vehicles (MPV) being used to transport students on field trips and other activities:
Combined Single Limit (CSL) or Bodily Injury Limit - per person / per accident
____ Yes
____ No
Insurance Agent_________________________________________________________
Address_________________________________________Telephone______________
I certify that insurance policies, subject to their terms, conditions, and exclusions are at present in force with the company indicated and that the information above is correct.
______________________________________ __________________________
Signature of Owner / Insured Date
This information above has been verified by:
______________________________________ _________________________
Signature of Principal or Designee Date