RETURN TO CSUN HOMEPAGE
Insurance & Risk Management
ENVIRONMENTAL HEALTH & SAFETY
TEL NO: (818) 677-2079
FAX NO: (818) 677-5853
MAIL DROP: 8284
:
Student Authorization to Operate
Privately Owned Vehicle
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NAME: STUDENT ID: DRIVERS LICENSE #: STATE: EXP DATE:
COURSE/ORGANIZATION: VEHICLE LICENSE #:
PROGRAM / ACTIVITY: MAKE / MODEL:
DESTINATION: NAME OF VEHICLE'S REGISTERED OWNER:
DEPARTURE/DATE/TIME: RETURN/DATE/TIME: INSURANCE PROVIDER: POLICY NO:

PASSENGERS TRAVELING IN THE VEHICLE:
1. 2.
3. 4.
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1.
CERTIFICATION:
  I hereby certify that, whenever I drive a privately owned vehicle to or from a University-affiliated event, I will have a valid driver's license in my possession, all persons in the vehicle will wear safety belts, and the vehicles shall always be:

 
1.
Covered by liability insurance for the minimum amount prescribed by State Law ($15,000 for personal injury to, or death of one person; $30,000 for injury to, or death of, two or more persons in one accident; $5,000 property damage).
2.
Equipped with safety belts in operational condition.
3.
To the best of my knowledge, the vehicle is in safe mechanical condition as required by law and adequate for the work to be performed.
  I further certify that I have no outstanding traffic warrants.

  I further certify that while using a privately owned vehicle on University-affiliated business, I will report all accidents to Office of Environmental Health & Safety (677-2079) and form Std. 270 will be completed and filed within 48 hours of the accident.

 

I understand that in the case of an accident my personal vehicle insurance will be the primary coverage.

Student Signature: ______________________________________ Date: ___________
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2.
Approval:
  Proof of insurance has been verified and use of a privately owned vehicle on State business is approved:

Signature & Title: ________________________________________ Date: ___________