ADM-1037 (7-14)
P.O. Box 14770, Scottsdale, AZ 85267-4770
8475 E. Hartford Dr., Scottsdale, AZ 85255
(
480) 991-7889 WATS (800) 848-8860
Fax (480) 948-1394 Toll Free (866) 240-8807
P.O. Box 571770, Murray, UT 84157-1770
5373 S. Green St., Suite 525, Murray, UT 84123
(
801) 290-1144 WATS (800) 594-8900
Fax (801) 290-1160 Toll Free (800) 332-9285
COMMERCIAL DRIVER EMPLOYMENT HISTORY
(Public Auto)
Insured Name: Policy No.:
Driver Name: Date of Birth: License Number:
Total Years Experience:
Experience listed should be for the same type of equipment you will be driving on this policy. The Commercial License
obtained date should be the date of license for the same type of equipment.
Including Current Employer, list in order of most recent employer first. MUST HAVE TWO FULL YEARS EXPERIENCE.
Employer: Phone:
Address:
Amount of Experience: Taxi/Livery % Limousine/Charter % All Other %
Experience transporting wheelchair bound and/or special needs passengers %
Driving Vehicle Types Listed: 1-7 pass. % 8-16 pass. % 16 or more %
Explain All Other:
Date of Employment: From (MO/YR): To (MO/YR):
Radius of Use: 0–100 Miles 101–300 Miles 301–500 Miles Over 500 Miles
Employer: Phone:
Address:
Amount of Experience: Taxi/Livery % Limousine/Charter % All Other %
Experience transporting wheelchair bound and/or special needs passengers %
Driving Vehicle Types Listed: 1-7 pass. % 8-16 pass. % 16 or more %
Explain All Other:
Date of Employment: From (MO/YR): To (MO/YR):
Radius of Use: 0–100 Miles 101–300 Miles 301–500 Miles Over 500 Miles
Employer: Phone:
Address:
Amount of Experience: Taxi/Livery % Limousine/Charter % All Other %
Experience transporting wheelchair bound and/or special needs passengers %
Driving Vehicle Types Listed: 1-7 pass. % 8-16 pass. % 16 or more %
Explain All Other:
Date of Employment: From (MO/YR): To (MO/YR):
Radius of Use: 0–100 Miles 101–300 Miles 301–500 Miles Over 500 Miles
Have you had any accidents in the last three years? ........................................................................................ Yes No
Have you had any tickets in the last three years? ............................................................................................. Yes No
If yes, please list dates and violations:
The undersigned applicant represents that the information provided he
rein is true and correct. I further understand that by
applying for insurance, I authorize Scottsdale Insurance Company to verify the information provided above.
Signature of the Nam
ed Insured or Driver Date
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signature
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