Garden Grove Unified School District
Office of Business Services
Use of Private Vehicle
Name: _____________________________________
Date of Birth: _____________________
Driver's License #: ___________________________
Exp. Date: ________________________
Year/Make of Vehicle:
____________________________________________________________
Vehicle License #: ________________________
Insurance Carrier/Agent: ______________________ Phone:
___________________________
Liability Limits: ______________________________ Policy
#: _________________________
Expiration Date: __________________________
Driving Restrictions:
_____________________________________________________________
I certify the above information is correct and the insurance
coverage is in force. I understand
I must have liability coverage in force and agree to advise the "District", in
writing, of any
changes in the above information. Attached is a copy of my "Insurance
declaration"; showing
policy number, effective/expiration dates and bodily injury liability limits of
$100,000/$300,000.
I further
certify that the above vehicle is mechanically safe.
_______________________________________
Date: _______________________________
Owner of Vehicle Signature
_______________________________________ Date:
_______________________________
Driver Signature
NOTE: If you drive your personal automobile while on District Business and
you are involved in
an
accident, by law your liability insurance is used first. The District
liability policy would be used
only
after your policy limits have been exceeded. The District does not cover,
not is responsible
for,
comprehensive and collision coverage to your vehicle.
I have read the above and approve the use of this vehicle for the purpose
stated.
________________________________________ Date:
_______________________________
Principal or Department Head
(Refer to Guidelines Part 1)
09/08/05
Form 9702.98