Form DSD CDTS-10 Insurance Certificate - Illinois

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OFFICE OF THE SECRETARY OF STATE
COMMERCIAL DRIVER TRAINING SECTION
STATE OF ILLINOIS: SS
650 ROPPOLO DRIVE, ELK GROVE VILLAGE 60007
CDTS-10.6
JESSE WHITE, SECRETARY OF STATE
INSURANCE CERTIFICATE
(PLEASE PRINT OR TYPEWRITE)
(THIS FORM MUST BE COMPLETED AND ATTACHED TO “SCHEDULE II-DRIVER TRAINING SCHOOL MOTOR VEHICLE FLEET”
AND ALL SUPPLEMENTS (SCHEDULE II(a) CONTAINING ADDITIONS TO THE DRIVER TRAINING SCHOOL MOTOR VEHICLE FLEET.)
POLICYHOLDER
NAME OF POLICYHOLDER
STREET ADDRESS OF POLICYHOLDER
CITY
ZIP Code
STATE
The Undersigned Insurance Carrier or Company certifies:
1. This it is solvent.
2. That it is authorized to do business in the State of Illinois.
3. That the motor vehicles listed and described herein are covered by the policy or policies of insurance designated.
4. That the policy or policies of insurance listed herein provide bodily injury and property damage liability insurance on the (number of vehicles)
motor vehicles listed below, while used for driving instruction, insuring the liability of the above-named driving school, its instructors and any
person taking instruction in at least the following amounts: $50,000.00 for bodily injury to or death of one person in any one accident and, subject
to said limit for one person, $100,000.00 for bodily injury to or death of two or more persons in any one accident and the amount of $10,000.00 for
damage to property of others in any one accident.
5. That the policy or policies of insurance designated herein shall not be cancelled, revoked, terminated or otherwise cease to be effective and until
ten days prior written notice is given to the Secretary of State, Driver Training School Division.
INSURANCE CARRIER OR COMPANY
NAME OF INSURANCE CARRIER OR COMPANY
PHONE NO.
CERTIFICATION DATE
MO.
DATE
YR.
STREET ADDRESS OF INSURANCE CARRIER OR COMPANY CITY
ZONE
STATE
INSURED VEHICLES
OWNED
LEASED
EXPIRATION DATE
YEAR
MAKE
SERIAL NO.
(x)
(x)
POLICY NO.
MO.
DAY
YR.
1
2
3
4
5
6
7
The undersigned swears (affirms): that he is an authorized agent for the above-named insurance carrier or company: that he is authorized to execute this
affidavit: that he has read the foregoing certificate; and that all statements and matters contained therein are true in substance and in fact.
for
(Signature of Authorized Agent)
(Name of Carrier or Company)
(Street Address)
(Phone)
(Address)
(City)
(State)
(City)
(State)
HAVE A NOTARY COMPLETE THE BOX BELOW
Subscribed and sworn to before me this ____________________ day of __________________________________ 19 ______
SEAL
(Notary Public)
Notary's Address
OFFICE OF THE SECRETARY OF STATE
COMMERCIAL DRIVER TRAINING SECTION
STATE OF ILLINOIS: SS
650 ROPPOLO DRIVE, ELK GROVE VILLAGE 60007
CDTS-10.6
JESSE WHITE, SECRETARY OF STATE
INSURANCE CERTIFICATE
(PLEASE PRINT OR TYPEWRITE)
(THIS FORM MUST BE COMPLETED AND ATTACHED TO “SCHEDULE II-DRIVER TRAINING SCHOOL MOTOR VEHICLE FLEET”
AND ALL SUPPLEMENTS (SCHEDULE II(a) CONTAINING ADDITIONS TO THE DRIVER TRAINING SCHOOL MOTOR VEHICLE FLEET.)
POLICYHOLDER
NAME OF POLICYHOLDER
STREET ADDRESS OF POLICYHOLDER
CITY
ZIP Code
STATE
The Undersigned Insurance Carrier or Company certifies:
1. This it is solvent.
2. That it is authorized to do business in the State of Illinois.
3. That the motor vehicles listed and described herein are covered by the policy or policies of insurance designated.
4. That the policy or policies of insurance listed herein provide bodily injury and property damage liability insurance on the (number of vehicles)
motor vehicles listed below, while used for driving instruction, insuring the liability of the above-named driving school, its instructors and any
person taking instruction in at least the following amounts: $50,000.00 for bodily injury to or death of one person in any one accident and, subject
to said limit for one person, $100,000.00 for bodily injury to or death of two or more persons in any one accident and the amount of $10,000.00 for
damage to property of others in any one accident.
5. That the policy or policies of insurance designated herein shall not be cancelled, revoked, terminated or otherwise cease to be effective and until
ten days prior written notice is given to the Secretary of State, Driver Training School Division.
INSURANCE CARRIER OR COMPANY
NAME OF INSURANCE CARRIER OR COMPANY
PHONE NO.
CERTIFICATION DATE
MO.
DATE
YR.
STREET ADDRESS OF INSURANCE CARRIER OR COMPANY CITY
ZONE
STATE
INSURED VEHICLES
OWNED
LEASED
EXPIRATION DATE
YEAR
MAKE
SERIAL NO.
(x)
(x)
POLICY NO.
MO.
DAY
YR.
1
2
3
4
5
6
7
The undersigned swears (affirms): that he is an authorized agent for the above-named insurance carrier or company: that he is authorized to execute this
affidavit: that he has read the foregoing certificate; and that all statements and matters contained therein are true in substance and in fact.
for
(Signature of Authorized Agent)
(Name of Carrier or Company)
(Street Address)
(Phone)
(Address)
(City)
(State)
(City)
(State)
HAVE A NOTARY COMPLETE THE BOX BELOW
Subscribed and sworn to before me this ____________________ day of __________________________________ 19 ______
SEAL
(Notary Public)
Notary's Address

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