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: _____________________
Drivers 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.
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