Mentor Driving Insurance Form

Mentor Driving/ Insurance Information

Laura Wilson – Director

mailing address: 551 Calvary Road, Nottingham, PA 19362

Hello Mentors Matter Volunteers,

Mentors Matter requests your driver’s insurance for the purpose of transporting students/ mentors in your vehicle while acting in a volunteer position with the Mentors Matter program. Please list your driver and vehicle information below and return this form to the Director.

Thank you as always for your support of Mentors Matter and thank you for sharing your experience!

Mentor Volunteer Driver Information

Name: _______________________________________ Date of Birth: _______________________

Address, City, State and Zip Code: _________________________________________________________________________________

_________________________________________________________________________________

Phone: _________________________ cell/work: _________________________________________

e-mail: ________________________________

Driver’s License Number: ______________________________ State: _______

Expiration Date: _____________ Vehicle License Number # _____________________

Vehicle Make and Model: _________________________________ Color: ____________________

Insurance Company and contact name/number: __________________________________________

_________________________________________________________________________________

Policy Number: _________________________

Please verify that you have insurance limits of 100/300 or 300 CSL- yes no

I ____________________________________ do not hold Mentors Matter, their insurance company, sponsoring agency or person (s) associated with the program liable for any accident/injury I may have while driving during a Mentors Matter activity.

Signature: ___________________________________ Date: _________________________