EEAE-AR - Proof of Auto Liability Insurance**
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.
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): _______________________________________________________
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.)