PERSONAL VEHICLE USE
Name: _______________________________ Phone________________ DOB:__________________
Driver's License #: _________________________Exp. Date:_________________
Year/Make of Auto: ______________________________
Vehicle License #:___________________________________
Insurance Carrier: ____________________________Phone: ________________
Liability Limits: _________________ Policy #:_____________________
Expiration Date:__________
I certify that the above information is correct and that the insurance coverage is in force. I understand
that while driving my personal vehicle in the course of my duties with the college that I must have
liability insurance coverage and a valid driver’s license as required by the State of California. I agree to
advise the college, in writing, of any changes in the above information. I further certify that the above
vehicle is mechanically safe.
If you drive your personal automobile while on college business and you are involved in an accident, by
law your liability insurance policy is used first. The college liability coverage would be used only after
your limits have been exceeded. The college does not provide comprehensive or collision coverage to
your vehicle.
All persons driving on college business will: (1) follow the most direct route; (2) avoid unnecessary
stops; (3) transport only authorized persons, no guests; (4) transport no more than 9 students, no
matter what size of vehicle; and (5) ensure that all vehicle occupants use seat belts if available in the
vehicle
Attach a photocopy of the following: (1) “Proof of Insurance” provided by your automobile insurance
company that indicates expiration date of insurance, and (2) driver’s license. The college may obtain a
driving record check from the California Department of Motor Vehicles.
Signed____________________________________________Date_________________
Site_______________________________________________Purpose______________
Approval___________________________________________Date_________________
