Driver Insurance Consent

"*" indicates required fields

It is understood that my employment requires (or may require) me to drive either a company owned vehicle or my own vehicle on company business. I understand that my employer and/or the insurance company writing my employer’s insurance requires my driver’s insurance policy to be verified.

By this letter, I hereby authorize my employer to access and obtain the necessary motor vehicle records, including my driver insurance. I authorize my employer to verify my insurance policy and my insurance agency or agent to release information regarding my driver policy to my employer.

This authorization will be valid until such time I leave my employer.

Name*

First Last

Date of Birth*

Email*

Drive Insurance Policy Number*

Agency Issued*

Make of Vehicle Covered by Policy*

Model of Vehicle Covered by Policy*

Year of Vehicle Covered by Policy*

Signature*

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Date*