ZIPCAR INSURANCE COVERAGE ACKNOWLEDGEMENT

Applicant: (print name): ________________________________________________________________

Thank you for your membership application in the Zipcar Program on the Dartmouth campus. We want to ensure that you and your family have a clear understanding of the insurance coverage provided to Zipcar Members who are under 21 years of age. According to the Member Agreement, drivers under 21 years of age are covered only up to the state minimum mandated levels, which in New Hampshire are $25,000 per injured person up to a total of $50,000 per accident for Bodily Injury, and Property Damage Liability coverage of $25,000.

We strongly suggest you or your parent/guardian check with your private auto insurance carrier to see if your current policy provides any additional protection and/or to see if you can purchase additional protection.

Dartmouth is simply facilitating the use of Zipcar reservations through an agreement with Zipcar. Dartmouth is not, under any circumstances, providing any liability or physical damage insurance coverage for students who rent from the company for personal use.

If you are an independent student please signify that you understand this limitation in coverage by signing below and emailing this form to transportation.services@dartmouth.edu or faxing to (603)-646-1205. If you are not an independent student, please signify that your parent/guardian understands this limitation in coverage by having them sign below and emailing this form to transportation.services@dartmouth.edu or faxing to (603)-646-1205. As soon as we receive your affirmative response, we will forward your membership application to Zipcar. Please note Zipcar has a strict policy of checking applicants’ driving records. Zipcar will approve or deny your application based on this record and Zipcar’s other standard requirements.

************************************************************************************ Independent student acknowledgement: I understand the limitations in the Zipcar insurance coverage and still wish to submit my application for membership in the program.

Applicant's signature: _______________________________________ Date: _____________________

************************************************************************************ Parent/Guardian acknowledgement: I understand the limitations in the Zipcar insurance and have reviewed the program and the Member agreement and approve the above named applicant for membership in the program.

Print Name of Parent/Guardian: _________________________________________________________

Signature of Parent/Guardian: __________________________________________________________

Date: ___________________________________ ************************************************************************************

AFTER SIGNING THIS ACKNOWLEDGEMENT FORM, PLEASE EMAIL/FAX TO: transportation.services@dartmouth.edu/ (603)-646-1205