EEBB-AR – Proof of Vehicle Liability Insurance

You will be utilizing your private vehicle for business purposes. Please be aware that in the event of an accident, your insurance will be primary coverage. You are required to provide proof of automobile liability insurance to JCESD. Your insurance must meet or exceed minimum requirements as established by the State of Oregon and as set by the JCESD.

Please COMPLETE the following, attaching a copy of your current “Proof of Insurance Card”, and providing information requested. SIGN where indicated and RETURN to the program administrator PRIOR TO THE DATE OF THE EVENT.

Insurance Company Name: Effective Date: (not agent’s name)

Policy Number: Policy Limits:

Current minimum limits are: $25,000 per person/$50,000 per accident for bodily injury; $10,000 per accident for property damage; $25,000 per person/$50,000 per accident for uninsured motorist coverage; $10,000 per accident for personal injury protection. JCESD recommends the employee to carry a minimum of $100,000 per person/$300,000 per occurrence liability coverage.

Are you over 21 years of age? ☐ YES ☐ NO Oregon Driver License No.:

I agree to notify JCESD immediately in the event of a lapse or change in the above referenced insurance coverage and attest to the accuracy of the information provided on this form.

Signature: Date:

Name: (as it appears on your driver’s license)

Address: Daytime Phone:

Failure to complete this form and demonstrate valid personal vehicle insurance coverage may result in the withholding of mileage reimbursement payments and/or disciplinary action.