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