STUDENT’S CERTIFICATION - PRIVATELY OWNED VEHICLES

DATE:_________________

As required by Section 10-101 (b) of the Illinois Vehicle Code (625 ILCS 5/10-101) every student of the State who operates a vehicle not owned, leased or controlled by the State shall procure insurance in the limit of the amounts of liability not less than the amounts required in Section 7-203 of the Act. Pursuant to Section 7-203 of the Illinois Vehicle Code (625 ILCS 5/7-203) , I CERTIFY that I possess in my name auto liability insurance in at least the following amounts: $25,000 for bodily injury to or death of any one person in any one motor vehicle accident; $50,000 for bodily injury to or death of 2 or more persons in any one motor vehicle accident; and $20,000 for injury to or destruction of property of others in any one motor vehicle accident.

As required by the Travel Regulation Council (SUBPART C Section 3000.300, (f) (1)), I CERTIFY that I am a duly licensed driver in the state of Illinois.

As stated in the State of Illinois auto liability self-insured plan administered by the Risk Management Division of CMS, I understand that if I operate my privately-owned vehicle on State business and an accident occurs, my personal coverage will be PRIMARY.

If for any reason there is a change which affects the above paragraphs, I will immediately notify Business Services of that change.

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Student’s Name (please print or type) Student’s Signature

Expires 6/30/2020