Volunteer Driver Application - Wye Bible Church

Application for Volunteer who will Drive Youth

The church requires volunteer drivers of private vehicles to have a minimum amount of liability insurance. (1) $100,000 liability per person for bodily injury; (2) $300,000 liability per incident for bodily injury for all vehicle occupants; and (3) $100,000 liability for property damage and the same coverages for uninsured/underinsured drivers.

All references to Church in this application mean Wye Bible Church. By signing and submitting this application, you grant the church permission and authorization to verify any information provided in this application and to conduct any driver or criminal record check deemed appropriate by the church.

Section 1: Personal Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone*

Number Years Driving Experience*

Section 2: Insurance Information

The church requires volunteer drivers of private vehicles to have a minimum amount of liability insurance. (1) $100,000 liability per person for bodily injury; (2) $300,000 liability per incident for bodily injury for all vehicle occupants; and (3) $100,000 liability for property damage and the same coverages for uninsured/underinsured drivers.

I agree to have Wye Bible Listed at an additional insured of certificate holder.

Insurance Company Name and Policy #*

Agent Name*

Agent Phone*

Bodily Injury Liability Limit*

Property Damage Liability Limit*

Section 3: Driver Record Information

Please answer the following. If answering yes, please attach a sheet to this form describing the nature of the ticket(s), infraction(s), or accident(s) with cause. Note: The church may not use volunteers who answer yes to any of the following:

Have you been in an accident within the last three (3) years?*

Yes
No

Have you been ticketed for moving violations within the last three (3) years?*

Yes
No

Have you been convicted or has your license been revoked/suspended for reckless/negligent operation of a vehicle?*

Yes
No

Permitting an unlicensed person to drive*

Yes
No

Driving while under license suspension/revocation DWI/DUI of alcohol or drugs*

Yes
No

Using any motor vehicle in the commission of a felony*

Yes
No

Unlawfully leaving the scene of an accident*

Yes
No

Unlawfully transporting a controlled substance or hazardous material*

Yes
No

Eluding an officer*

Yes
No

Negligent homicide/aggravated assault arising out of the use of a motor vehicle*

Yes
No

Hit and run*

Yes
No

Operating a vehicle without owner’s authority (grand theft)*

Yes
No

Multiple moving violations*

Yes
No

Section 4: Drivers Requirements and Declarations

I certify that for the calendar year below for which I have volunteered to be a driver that: I possess a valid driver's licens from the state listed below.*

Yes
No

Calendar Year

State

I have consulted my insurance agent to ascertain if there are any liability policy limits or exclusions regarding transporting church groups that might affect my ability to meet the qualifications for a volunteer driver as provided herein, and that I am not aware of any such limits or exclusions after talking with my insurance agent.*

Yes
No

I have informed my insurance agent of my intention to use the vehicle and to be a volunteer driver for church activities to determine whether a passenger endorsement is required to participate as a volunteer driver I will maintain the minimum insurance coverage required by the church for volunteer vehicle(s) listed in Vehicle Information and only volunteer to drive when such insurance policies and coverage listed in Insurance Information are in force.*

Yes
No

When driving a privately owned vehicle, I understand that in case of any accident, injury, or vehicle damage, the church’s liability insurance policy does not provide primary or direct insurance on my vehicle. The church’s insurance may take effect only after my personal auto insurance limits are exhausted and does not provide any comprehensive or collision coverage on my vehicle. I also understand and acknowledge that any additional automobile liability insurance protection that may be provided under the church’s comprehensive general liability insurance policy is only for authorized drivers while transporting passengers in privately-owned vehicles on church sponsored or sanctioned events. I understand that the church’s insurance is only for an amount in excess of the limit of liability provided by the private vehicle owner’s or driver’s liability insurance policy. Damage to any private vehicle, including the owner’s, is the responsibility of the volunteer driver.*

Yes
No

To my knowledge, my vehicle has a current, valid registration and operating license, is in safe operating condition (brakes, tires, etc.), and complies with all applicable state laws in the state in which it is registered for vehicle inspections.*

Yes
No

I am in good physical and mental health, it is safe for me to drive and neither my driver’s license nor my ability to operate a vehicle is limited by any medical, physical, or emotional restriction or condition.*

Yes
No

I understand that, if approved as a Volunteer Driver, I have a continuing obligation to advise the church of any change in information provided on this form including, but not limited to, involvement in a car accident in which I am cited, any citations for moving violations, non-renewal of license, termination of license, change of insurance company, change in amounts of insurance coverage, termination of insurance, or change in vehicle. I will promptly provide this information.*

Yes
No

Persons in my vehicle will be seated and secured with individual working seatbelts in both the front and back seats. (No double belting is permitted)*

Yes
No

I will comply with laws, and the laws of other states in which I travel on a church trip, with regards to use and security of child restraint seats, lap/shoulder belt seating positions, restrictions on use of booster seats or other safety systems (including, but not limited to occupancy and seat facing designations for seats exposed to air bags).*

Yes
No

I will comply with the Safe Environment Policy and Training Manual, a copy of which will be provided to me, if my application to be a Volunteer Driver is accepted.*

Yes
No

I affirm that I will carefully transport all persons under my care, including obeying all traffic laws and the church transportation policy.*

Yes
No

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.*

By checking this box and typing my name below, I am electronically signing my Volunteer Driver Application form.

Name*

First Last

Date*

Vehicle Owner's Name (if different)

First Last

Date

Make, Model & Year of Vehicle*

License Plate Number*