Student Authorization to Operate Privately Owned Vehicle

Insurance & Risk Management Forms

Student Authorizaiton to Operate Privately Owned Vehicle for any University-Affiliated Program or Trip

INSURANCE & RISK MANAGEMENT

Phone: (818) 677-2079

Fax: (818) 677- 5853

Mail Drop: 8284

I. Program/Trip Information:
NAME (Last, First, MI):		STUDENT ID:
COURSE/ORGANIZATION:		PROGRAM/ACTIVITY:
DESTINATION/LOCATION OF ACTIVITY:
DEPARTURE DATE & TIME:	RETURN DATE & TIME:

II. Vehicle Information:

DRIVERS LICENSE #:

STATE:

EXPIRATION DATE:

VEHICLE LICENSE #:

MAKE:

EXPIRATION DATE:

NAME OF VEHICLE'S REGISTERED OWNER:

INSURANCE PROVIDER:

POLICY #:

PASSENGERS TRAVELING IN VEHICLE:	1.	2.
	3.	4.

III. 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 California State Law ($15,000 for injury/death to one person; $30,000 for injury/death to, more than one person; $5,000 for property damage).
	2. Equipped with safety belts in operating condition for all passengers and driver.
	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 CSUN’s Office of Insurance & Risk Management (677-2079) and form Std. 270 will be completed and filed within 48 hours of the accident.
I understand that this authorization only applies to the above specified University-affiliated Program or Activity and that in the case of an accident my personal vehicle insurance will be the *primary coverage.*

IV. Approval:
Proof of insurance has been verified and use of a privately owned vehicle on State business is approved.

Authorizer's Signature: ____________________________________		Date: ____________
Print Name:	Title: __________________________________