Verification Of Driver'S License And Proof Of Auto Insurance Form

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University Corporation, San Francisco State
This form is REQUIRED
Reset
If the answer is no, check no and sign and date at the bottom
Verification of Drivers License & Proof of Automobile Insurance
1.
Will your automobile be used routinely for business while you are employed by the
Corporation (commuting to and from work is not considered using your vehicle for
business)?
Yes __________
No ____________
If you answered “No” to the above question, complete #7 & #8 at the bottom of this form.
If you answered “Yes” to question #1, complete the remainder of this form.
As required by our liability carrier, employees whose duties necessitate driving vehicles in the
course of employment need to maintain certain acceptable standards. Drivers will have less than
4 (four) violation points in a 12 (twelve) month period or less than 6 (six) points in an 18
(eighteen) month period.
2. Name on Driver’s License:____________________________________________
3. Date of Birth: ______________________________________________________
4. Driver’s License Number:____________________________Class License:_____
5. Expiration Date: ____________________________________________________
6. State of Licensing: __________________________________________________
If an employee is permitted to use a personal vehicle in the course and scope of their
employment, the employee shall provide proof of personal automobile liability insurance with
.
coverage and limits that meet California’s minimum requirements
7. Print Name:_______________________________________________________
8. Signature: ___________________________________Date: ________________
PLEASE NOTE: As a means of addressing necessary measures aimed at reducing losses related
to vehicle operation and a requirement regarding our insurance liability coverage, the Corporation
is enrolling in the Employer Pull Notice (EPN) Program offered by the DMV. You will be
required to complete an Authorization for Release of Driver Record Information so we may
enroll you in the EPN program in the event you routinely use your personal automobile on
business. An application and further information will be provided if you answered “Yes” to # 1
above.

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