Fillable Printable Driver Education Motorcycle Insurance Certificate

Driver Education Motorcycle Insurance Certificate

MINNESOTA DEPARTMENT OF PUBLIC SAFETY

DRIVER EDUCATION PROGRAM

MOTORCYCLE INSURANCE CERTIFICATE

Minnesota Rules 7411.0270

Name of School

Name of Insured (Last, First, and Middle Name)

Date of Birth (Month, Day, Year)

Street Address City State Zip Code

The undersigned insurance carrier or company certifies:

A. That it is solvent.

B. That it is authorized to do business in the state of Minnesota.

C. That the motorcycle listed and described herein are covered by the policy or policies of insurance designated.

D. That the policy or policies of insurance listed herein provide at least $100,000 because of bodily injury to, or

death of, any one person in any one accident; at least $300,000 because of bodily injury to, or death of, two or

more persons in any one accident; at least $50,000 because of damage to, or destruction of, property of others in

any one accident; at least $20,000 for medical expenses; and at least the minimum amount of uninsured motorist

coverage, when any portion of the program instruction is conducted on public streets.

E. That the policy or policies of insurance designated herein shall not be cancelled, revoked, terminated or

otherwise cease to be effective unless and until thirty (30) days prior written notice is given to the Minnesota

Department of Public Safety, Driver and Vehicle Services, 445 Minnesota Street, Suite 176, St. Paul, MN

55101-5176.

Name of Insurance Carrier or Company

Street Address City State Zip Code

Business Phone (Include Area Code) Policy Number

Year Make Model Style VIN Own or Lease

The undersigned swears (affirms) that s/he is an authorized agent for the above named insurance

carrier or company; that s/he is authorized to execute this affidavit; that s/he has read the foregoing

certificate; and that all statements and matters contained therein are true in substance and in fact.

__________________________________________________________ ______________________

SIGNATURE OF AUTHORIZED REPRESENTATIVE DATE

PS36016-04