Form STD.265 "Insurance Verification and Authorization to Operate Privately Owned / Rented / Leased Aircraft on State Business" - California

What Is Form STD.265?

This is a legal form that was released by the California Department of General Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 1991;
  • The latest edition provided by the California Department of General Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form STD.265 by clicking the link below or browse more documents and templates provided by the California Department of General Services.

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Download Form STD.265 "Insurance Verification and Authorization to Operate Privately Owned / Rented / Leased Aircraft on State Business" - California

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STATE OF CALIFORNIA
INSURANCE VERIFICATION AND AUTHORIZATION TO OPERATE PRIVATELY
OWNED / RENTED / LEASED AIRCRAFT ON STATE BUSINESS
STD. 265 (Rev. 10/2019)
TO
FROM
AUTHORIZATION EFFECTIVE
(Maximum One Year)
Completion of this form does not constitute prior approval to use a privately owned/rented/leased aircraft.
Supervisors must evaluate the use of aircraft and MAY authorize use whenever it is the most economical
means available or is otherwise in the best interests of the State.
I. EMPLOYEE / PILOT CERTIFICATION
I hereby certify that:
1. I have a valid Federal Aviation Agency (FAA) pilot's license which will be in my possession whenever I fly a privately-owned/rented/leased aircraft
on State business; that all persons in the aircraft will wear safety belts and that the aircraft shall always be equipped with safety belts and required
safety equipment.
2. In every case, the aircraft is in accordance with applicable FAA regulations and properly equipped for the type of flying to be performed.
3. To the best of my knowledge, the aircraft is in safe mechanical condition, as required by law.
4. Passengers will only be carried under conditions stated in Title 2, California Code of Regulations, Section 559.628 of the Department of Personnel
Administration Rules.
5. If passengers are carried, passenger liability insurance will be in effect.
6. There is a current insurance policy with liability limits of at least: (a) bodily injury liability of $100,000 for each person and $500,000 for each occurrence,
property damage liability of $100,000 for each occurrence or $500,000 combined single limit; and (b) passenger bodily injury liability of $100,000
for each person, if passengers are carried. Said policy is available for review and audit for at least two years from the date shown above. The insurance
company has named the State of California as an additional insured on the insurance policy.
I have read Section 599.628 of the Department of Personnel Administration Rules and the State Administrative
Manual Sections governing the use of privately-owned/rented/leased aircraft on State business and agree to
comply therewith.
EMPLOYEE'S SIGNATURE
EMPLOYEE'S NAME PRINTED
LICENSE TYPE HELD
LICENSE NUMBER
DATE SIGNED
II. SUPERVISOR'S AUTHORIZATION AND VERIFICATION OF INSURANCE REQUIREMENTS
TITLE
DATE SIGNED
SUPERVISOR'S SIGNATURE
DISTRIBUTION:
SUPERVISOR - Original
ACCOUNTING - Copy
EMPLOYEE: - Copy
Clear
Print
STATE OF CALIFORNIA
INSURANCE VERIFICATION AND AUTHORIZATION TO OPERATE PRIVATELY
OWNED / RENTED / LEASED AIRCRAFT ON STATE BUSINESS
STD. 265 (Rev. 10/2019)
TO
FROM
AUTHORIZATION EFFECTIVE
(Maximum One Year)
Completion of this form does not constitute prior approval to use a privately owned/rented/leased aircraft.
Supervisors must evaluate the use of aircraft and MAY authorize use whenever it is the most economical
means available or is otherwise in the best interests of the State.
I. EMPLOYEE / PILOT CERTIFICATION
I hereby certify that:
1. I have a valid Federal Aviation Agency (FAA) pilot's license which will be in my possession whenever I fly a privately-owned/rented/leased aircraft
on State business; that all persons in the aircraft will wear safety belts and that the aircraft shall always be equipped with safety belts and required
safety equipment.
2. In every case, the aircraft is in accordance with applicable FAA regulations and properly equipped for the type of flying to be performed.
3. To the best of my knowledge, the aircraft is in safe mechanical condition, as required by law.
4. Passengers will only be carried under conditions stated in Title 2, California Code of Regulations, Section 559.628 of the Department of Personnel
Administration Rules.
5. If passengers are carried, passenger liability insurance will be in effect.
6. There is a current insurance policy with liability limits of at least: (a) bodily injury liability of $100,000 for each person and $500,000 for each occurrence,
property damage liability of $100,000 for each occurrence or $500,000 combined single limit; and (b) passenger bodily injury liability of $100,000
for each person, if passengers are carried. Said policy is available for review and audit for at least two years from the date shown above. The insurance
company has named the State of California as an additional insured on the insurance policy.
I have read Section 599.628 of the Department of Personnel Administration Rules and the State Administrative
Manual Sections governing the use of privately-owned/rented/leased aircraft on State business and agree to
comply therewith.
EMPLOYEE'S SIGNATURE
EMPLOYEE'S NAME PRINTED
LICENSE TYPE HELD
LICENSE NUMBER
DATE SIGNED
II. SUPERVISOR'S AUTHORIZATION AND VERIFICATION OF INSURANCE REQUIREMENTS
TITLE
DATE SIGNED
SUPERVISOR'S SIGNATURE
DISTRIBUTION:
SUPERVISOR - Original
ACCOUNTING - Copy
EMPLOYEE: - Copy