Fillable Printable Driver Education Vehicle Insurance Certificate
Fillable Printable Driver Education Vehicle Insurance Certificate
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Driver Education Vehicle Insurance Certificate
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MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER EDUCATION PROGRAM
VEHICLE 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 motor vehicles 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 $250,000 because of bodily injury to, or
death of, any one person in any one accident; at least $500,000 because of bodily injury to, or death of, two or
more persons in any one accident; at least $100,000 because of damage to, or destruction of, property of others
in any one accident; at least $40,000 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