Statement Of Insurance On Private Vehicles Form printable pdf download

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STATEMENT OF INSURANCE ON PRIVATE VEHICLES

Required by F.S. 234.03 (4)

School Year _____________

School ___________________________________________________ Date ____________________

The School Board of Brevard County, Florida requires proof of insurance coverage in force on all

private vehicles used for the transportation of school sponsored groups on all in-county and out-of-

county trips. 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 (_____) _______-__________

Florida Driver's

License: Type _________________________________ Number ______________________________

VEHICLE INFORMATION

Vehicle Make __________________________________ Year ___________ Model _______________

License Tag _________________________________ Expiration Month / Year _________/_________

INSURANCE INFORMATION: THE SCHOOL BOARD OF BREVARD COUNTY RECOMMENDS THE

VEHICLE OWNER CARRY A LIMIT OF $200,000 COMBINED SINGLE LIMIT OR $100,000/$300,000

BODILY INJURY LIMIT.

Name of Insured(s) ________________________________ Policy Number _____________________

Insurance Company _________________________________________________________________

Policy period: From ___________________________________ To ____________________________

The vehicle owner’s policy provides the recommended limits of liability coverage.

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.

_________________________________________

___________________________________

Signature of Principal or Designee

Date

2/04

9/09

Statement Of Insurance On Private Vehicles Form