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EHIRE-206 1-17-03

Certificate of Liability Insurance

This is to certify that I have in force automobile liability insurance covering the operation of my car on official business and will maintain such coverage for the duration of my employment with the Cooperative Extension Service. Furthermore, that if cove rage is terminated, whatever the reason, I am to notify the Human Resource Office in writing.

Print Name

Employee Signature

Position Title

Date

Note: Cooperative Extension Service employees can be reimbursed for travel expense only if liability insurance is in force on the automobile(s) used for official business travel.

University of Arkansas Travel Insurance

Designation of Beneficiary:

I designate that the University of Arkansas travel insurance be payable in the following order of precedence:

1. Widow or Widower 2. Children 3. Parents 4. Estate 5. Next of kin (under Arkansas law)

OR

I designate as my beneficiary for the University of Arkansas Travel Insurance:

Name of Beneficiary:

Beneficiary’s Address:

Signature of Insured Employee: D at e:

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