EEAE-AR - Proof of Auto Liability Insurance**

Adopted: Unknown
Re-adopted: 12/4/01; 7/13/22

Dear [     ],

You have agreed to transport __________ students of the district to a field -trip function or for some other school-approved purpose. Please be aware that in the event of an accident, your insurance will provide primary coverage. In order to serve as a driver you will be required to provide proof of vehicle liability insurance. Your insurance must meet or exceed minimum requirements as established by the state of Oregon and as set by the district.

Please COMPLETE the following information, providing information requested. SIGN where indicated and RETURN to the school office four working days PRIOR TO THE DATE OF THE EVENT.

Insurance Company Name: ________________________ Expiration Date: ______________________
                                                       (not agent’s name)
Policy Number: ____________________________________________________
Policy Limits: _______________________________________________________

Current minimum limits are: $25,000 per person and $50,000 per accident for bodily injury; $20,000 per accident for property damage; $25,000 per person and $50,000 per accident for uninsured motorist coverage; and $15,000 per accident for personal injury protection.

School ____________________________________________________
Driver’s Name: ____________________________________________
Date of Birth: ______________________________________________
Insurance Company Name: __________________________________Effective Date: _______________
Policy Number: ___________________________________________________________________________
Oregon Driver’s License Number: ____________________________

Signature: ___________________________________________ Date: ________________

Name of volunteer verifying the above information                                                                                (as it appears on your driver license): _______________________________________________________
Address: _________________________________________________________________
Daytime Phone: ________________________________________________________

Return form to fiscal officer. If you do not have required coverage, you will not be allowed to transport students. (Insurance companies may increase coverage for specific dates.)