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Florida Annual Conference United Methodist Church

2007 Department for Ministry Protection

Church Trip Form

Continued from First Page

Driver Information and Authorization to Obtain Motor Vehicle Records: I am aware that motor vehicle reports may be obtained as part of the Florida Annual Conference United Methodist Church’s evaluation of my request to operate a church vehicle. The reports may be procured by the Florida Annual Conference United Methodist Church or its insurance broker/company representative(s), and may include information obtained from state motor vehicle departments, my driving record or an assessment of my insurability for the insurance program.

By signing below, I hereby provide my authorization for the Florida Annual Conference United Methodist Church and/or their insurance broker/company representative(s) to procure such information and reports about me from time-to-time as deemed appropriate, to evaluate my insurability or for other permissible purposes.

Driver #1:

Any Moving Violations in the Last Five Years:

  • Yes No (MVR Pulled

_________)

Driver’s Name:

( a s i t a p p e a r s o n D r i v e r s L i c e n s e ) D r i v e r s L i c e n s e N u m b e r :

(including state of issuance)

Date of Birth:

Signature of Driver

Date

Driver #2:

Any Moving Violations in the Last Five Years:

  • Yes No (MVR Pulled

_________)

Driver’s Name:

( a s i t a p p e a r s o n D r i v e r s L i c e n s e ) D r i v e r s L i c e n s e N u m b e r :

(including state of issuance)

Date of Birth:

Signature of Driver

Date

Administered by: Arthur J. Gallagher Risk Management Services Arthur J. Gallagher & Co. (Florida) 2255 Glades Road Suite 400 E Boca Raton, FL 33431 Phone: (800) 282-8011 ext. 126 Fax: (561) 892-3982 Additional information and all forms are available on the Florida Conference website (www.flumc.org) Revision Date: 12/18/2006

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