Parent/driver Insurance Verification Form printable pdf download

PARENT/DRIVER INSURANCE VERIFICATION FORM

(Please attach a copy of your current insurance card with this form.)

Name of Parent/Driver ____________________________________________________________________

LAST

FIRST

MIDDLE INITIAL

Address________________________________________________________________________________

City _________________________________________ State _______________ Zip ________________

Home Phone __________________________________ Cell Phone ________________________________

Driver’s License # ______________________________ Make of Vehicle ____________________________

Model _______________________________________ # of Seat Belts _____________________________

Insurance Company ______________________________________________________________________

Policy Number ________________________________ Expiration Date ____________________________

The Rock Academy Field Trip drivers are required to carry minimum liability insurance of a combined

single limit of $300,000 bodily injury and property damage (referred to as 100/300) plus

uninsured motorist coverage.

Liability $_____________________________________ Property Damage $_________________________

Medical $ ____________________________________ Uninsured Motorist $________________________

I understand that as the registered owner of the vehicle, the primary responsibility for all legal and insurance

issues arising from the use of my vehicle on the behalf of the school rests entirely with me. I understand that

the school’s liability insurance covers only registered Rock Academy students on a school-sponsored activity,

and is secondary to my personal auto and liability insurance.

___________________________________________

_______________________________________

PARENT/DRIVER SIGNATURE

DATE

___________________________________________________________

PRINT NAME

By law, the number of people in the vehicle cannot exceed that the number of seats and seat belts.

SEAT BELTS MUST BE USED BY EVERYONE IN THE VEHICLE – NO EXCEPTIONS.

Rock Academy

2277 Rosecrans St. • San Diego, CA 92106 • Phone: (619) 764.5200 • Fax: (619) 764.5201

Parent/driver Insurance Verification Form