UNC-CH SPORT CLUBS

TRAVEL INSURANCE FORM

 (All persons driving to club activities must sign a Travel Insurance Form before driving to an event.)

Club:                 ---- Aussie Rules Football Baseball Basketball (W) Cheerleading Crew Cricket Cycling Disc Golf Equestrian Field Hockey Football Golf Gymnastics Ice Hockey Judo Korean Karate Lacrosse (M) Lacrosse (W) Marathon Modernextension Official's Outing Racquetball Roller Hockey Rugby (M) Rugby (W) Sailing scuba Shotokan Karate Ski and Snowboard Soccer (M) HEELS Soccer (M) RAMS Soccer (W) HEELS Soccer (W) RAMS Softball Squash Swimming Tae Kwon Do Team Handball (M) Team Handball (W) Tennis (M) Tennis (W) HEELS Track & Field/Cross Country Triathlon Ultimate Frisbee (M) Ultimate Frisbee (W) Volleyball (M) Volleyball (W) Water Polo Water Ski Wrestling Other

Name of Driver

Email

Driver's License #        

State of Insurance      Expiration Date 

Owner of Vehicle

Name of Automobile Insurance Company

Automobile Insurance Policy Number

 Make/Model of Vehicle

By  typing my name, I certify that I have automobile insurance coverage that meets the requirements of law in the state of North Carolina.  I also certify that my driving record is satisfactory and the above information is correct and if an accident occurs while my car is driven to or from a club activity, I understand that my automobile insurance coverage may be the primary coverage.  In addition, I also certified my vehicle is in good working condition and meets the state of North Carolina’s vehicle inspection standards.

I have read and understood the above statement to be true, and I also certify the information I have provide is correct.

Name of person completing the form and certifying information