DRIVER ENDORSEMENT REQUEST

Insured Name
Driver Name
Driver Type (Company or Owner Operator)
If owner operator; Equipment VIN:
Purchase Date

MonthDayYear
Date
Equipment Make
Equipment Year
(If Equipment is over 15 years old, A request for pictures and inspection report will follow)
Equipment VIN
Driver Date of Birth

MonthDayYear
Date
Driver Social Security Number
Driver CDL Number and State
Years Continuous CDL Operator
List any accidents this driver has been involved in over the last 5 years
List any violations this driver has been involved in over the last 5 years
Provide (5 )Five Year Driver Employment History (be careful to leave NO time gaps)
Prior Employer Name
Date of Hire

MonthDayYear
Date
Date of Termination

MonthDayYear
Date
Reason for Termination
Position
If a driver Radius Driver Operated for this employer
Types of commodities hauled
Date of Hire

MonthDayYear
Date
Date of Termination

MonthDayYear
Date
Reason for Termination
Position
If a driver Radius Driver Operated for this employer
Types of commodities hauled
Prior Employer Name
Date of Hire

MonthDayYear
Date
Date of Termination

MonthDayYear
Date
Reason for Termination
Position
If a driver Radius Driver Operated for this employer
Types of commodities hauled
**If needed, use page 2 for additional employment History

By my signature below, I certify that all entries and information above are true and complete to the best of my knowledge. I authorize DUOA to obtain my motor vehicle and driving records, documents relating to my employment history with other companies, as well as any other document which may be classified as a consumer report as that term is defined by the Fair Credit Reporting Act. I hereby release employers, schools, healthcare providers, and other persons from all liability in responding to inquiries and releasing any information.
Driver Printed Name
Driver Signature

Clear
Date

MonthDayYear
Date
Page 2 Driver Endorsement Request
Prior Employer Name
Date of Hire

MonthDayYear
Date
Date of Termination

MonthDayYear
Date
Reason for Termination
Position
If a driver Radius Driver Operated for this employer
Types of commodities hauled
Prior Employer Name
Date of Hire

MonthDayYear
Date
Date of Termination

MonthDayYear
Date
Reason for Termination
Position
If a driver Radius Driver Operated for this employer
Types of commodities hauled
Prior Employer Name
Date of Hire

MonthDayYear
Date
Date of Termination

MonthDayYear
Date
Reason for Termination
Position
If a driver Radius Driver Operated for this employer
Types of commodities hauled
Prior Employer Name
Date of Hire

MonthDayYear
Date
Date of Termination

MonthDayYear
Date
Reason for Termination
Position
If a driver Radius Driver Operated for this employer
Types of commodities hauled
Prior Employer Name
Date of Hire

MonthDayYear
Date
Date of Termination

MonthDayYear
Date
Reason for Termination
Position
If a driver Radius Driver Operated for this employer
Types of commodities hauled
Should be Empty: