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  • Driver Declaration Form

    Uploaded by

    Luis Perez Garcia
    390 views4 pages
    This 4 page document is a driver's declaration form that must be completed and sent to an insurance company along with a recent driver's abstract and commercial vehicle operator record. It collects information about the driver's experience, claims history, and employment history over the past 3 years with at least 3 employers listed. The driver consents to the collection and sharing of their driving record for underwriting and fraud prevention. A broker must also confirm verifying the driver's experience with past employers.

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    This 4 page document is a driver's declaration form that must be completed and sent to an insurance company along with a recent driver's abstract and commercial vehicle operator record. It collects information about the driver's experience, claims history, and employment history over the past 3 years with at least 3 employers listed. The driver consents to the collection and sharing of their driving record for underwriting and fraud prevention. A broker must also confirm verifying the driver's experience with past employers.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    390 views4 pages

    Driver Declaration Form

    Uploaded by

    Luis Perez Garcia
    This 4 page document is a driver's declaration form that must be completed and sent to an insurance company along with a recent driver's abstract and commercial vehicle operator record. It collects information about the driver's experience, claims history, and employment history over the past 3 years with at least 3 employers listed. The driver consents to the collection and sharing of their driving record for underwriting and fraud prevention. A broker must also confirm verifying the driver's experience with past employers.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 4

    DRIVER’S DECLARATION FORM

    This form duly completed must be sent to Old Republic Insurance Company of Canada, including recent driver’s abstract & commercial
    vehicle operator record (maximum 90 days old). The Insurer’s authorization is required before hiring new drivers.

    DRIVER INFORMATION
    Name:

    License #: Date of Birth (MM/DD/YY):

    License Class: Policy number:

    DRIVER EXPERIENCE

    How Many Years of commercial driving experience How many years of US commercial Do you have experience handling
    under your current class of licence? driving experience do you have? refrigerated goods?

    Are you currently an (please specify)

    Driver Trainee
    Owner Operator Company Driver

    CLAIMS HISTORY (Please describe all accidents you were involved in for the last 3(three) years)

    Claims in the last three (3) years No Claims

    Date of accident Description and Location Liability (%) Amount Paid

    Page 1 of 4
    TRUCKING COMPANY EMPLOYMENT INFORMATION (minimum 3 years history must be provided)

    Important: All fields must be fully completed for each employment experience

    CURRENT EMPLOYER

    Company Name:

    Address:

    Supervisor’s Name:
    Phone #:
    Employment Start Date: Employment End Date:

    Commodities most often hauled for this employer:

    Type of vehicle (s) most often driven for this employer

    Tractor Straight Light Commercial


    Name of Insurance Company & Policy # (if known):

    CVOR# MC# / US DOT#

    PAST EMPLOYER 1

    Company Name:

    Address:

    Supervisor’s Name: Phone #:

    Employment Start Date: Employment End Date:

    Commodities most often hauled for this employer:

    Type of vehicle (s) most often driven for this employer

    Tractor Straight Light Commercial


    Name of Insurance Company & Policy # (if known):

    CVOR# MC# / US DOT#

    PAST EMPLOYER 2

    Company Name:

    Address:

    Page 2 of 4
    Supervisor’s Name: Phone #:

    Employment Start Date: Employment End Date:

    Commodities most often hauled for this employer:

    Type of vehicle (s) most often driven for this employer

    Tractor Straight Light Commercial


    Name of Insurance Company & Policy # (if known):

    CVOR# MC# / US DOT#

    PAST EMPLOYER 3

    Company Name:

    Address:

    Supervisor’s Name: Phone #:

    Employment Start Date: Employment End Date:

    Commodities most often hauled for this employer:

    Type of vehicle (s) most often driven for this employer

    Tractor Straight Light Commercial


    Name of Insurance Company & Policy # (if known):

    CVOR# MC# / US DOT#

    Driver’s Consent
    I hereby authorize Old Republic Insurance Company of Canada and its authorized agents to collect, use and disclose my driving record,
    automobile insurance policy history and automobile insurance claims history as permitted by law for the limited purposes necessary to
    assess the risk, to investigate and settle claims, and to prevent, detect and suppress fraud. If I am issued an automobile insurance policy
    or if I make a claim, this information may be pooled with information from other sources and may be subject to analysis for the limited
    purpose of preventing, detecting or suppressing fraud. For this purpose, the information also may be disclosed to i) fraud prevention
    organizations, other insurance companies and the police and ii) databases or registers used by the insurance industry to analyze and
    check information provided against existing information.

    This consent form is valid for the policy period, all extensions and renewals of the contract, as well as any other general insurance
    contract required or offered to the undersigned.

    Driver’s name (please print): Signature: Date:

    Page 3 of 4
    Broker’s Written Confirmation

    The undersigned, hereby declares having verified the above-mentioned driver with all listed former employers for at least the past 3
    years.

    Broker’s name (please print): Signature:


    Date:

    Notwithstanding, completion of this form is only for the confirmation of driving experience and
    does not eliminate the obligations of the insured to satisfy MTO and DOT standards.

    Page 4 of 4

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