Transportation Waiver Form Page 7
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8LOS ANGELES UNIFIED SCHOOL DISTRICT
BULLETIN NO. 5310.0
ATTACHMENT C
PRIVATE AUTOMOBILE DRIVER
CERTIFICATION OF LIABILITY INSURANCE
I hereby certify that I have automobile liability insurance which covers the driver and
all passengers in the automobile, and I have ascertained that my policy will cover me
and all passengers riding in the automobile in connection with the transport of
students, other employees or tangible goods for the following LAUSD authorized
employment duties or school activity:
________________________________________________________________
Covered Auto
Make: ___________________________________________
Model: ___________________________________________
My insurance company is: ____________________________________________
(
) ____________________________________________
Policy#
My insurance agent/broker is: __________________________________________
__________________________________________
(Telephone)
My driver's license number is: ________________________ Issue State: _______
Exp. Date: __________
Age: ___ (18-25) ___ over 25
Signature:
__________________________________________________
Printed Name:
__________________________________________________
Work Site Address: ____________________________________________________________
Home Address:
____________________________________________________________
Reviewed By: _____________________________________ Title: ______________________
(Site Administrator/Supervisor)
Date:
___________________________
LS3, Rev. 05/2010
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