University Corpo
rate Insurance
New Drivers of University Vehicles
The following information is required for all new drivers of University vehicles. The University
self-insures for collision/comprehensive and requires this information to determine whether
individuals are eligible to drive university vehicles. Please complete the following and return it to
the Corporate Insurance office – Support Services Building, Room 5100. (If you have any
questions about the collection, use or disclosure of this information, please contact the
Corporate Insurance Administrator at 519-661-2111 ext. 81135)
The
following department, ______________________________________________________,
requests that the person named below be added to our list of university drivers.
Driver Information:
Name
: ________________________________________
Home Address: ____________________________________ City: _____________________
Driver’s License Number: ______________________________________
How
long have you been licensed to drive? _________________
Hav
e you had an accident in the last 6 years? ________________
Hav
e you had any driving convictions in the last 6 years? ___________________________
Are
you presently insured on other automobile insurance policies? ___ Yes ____ No
(An
swer only if driving a truck or towing trailer)
What experience do you have driving this kind of vehicle?
____________________________________________________________________________
Driver signature: ______________________________ Date: __________________________
_____________________________________ ___________________________________
Department Approval Name (Please Print) Department Approval Signature
Note: The University provides our Insurance Broker with a list of all university drivers.
