Defensive Driving School Application

The school is located inside Diversified Insurance, LLC 2896 N Expressway, Suite A, Griffin, GA 30223

Office: 404-669-6941 ext 3 Email: driving@diversifiedshield.com
Contract - State-Certified Defensive Driving School #DI002371

In-person and Distant Learning Classes. All fees are NON-REFUNDABLE. If you miss your class for any reason, unless excused for medical reasons or military (physician's excuse or leave orders provided), you will need to reschedule and pay another tuition fee for the course. Physician excuse or leave orders allows you to reschedule only. See a date not listed, call our office at 404-669-6941 ext 3.
Class Schedule*
Looking for a date not listed, call our office. We have flexibility to add dates. Upon submission, you will receive a confirmation email.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Resident County *
Date of Birth*

MonthDayYear
Date
Driver's License/Contract Number*
Enter Driver's License Number only
Driver's License State*
Gender*

MF
Phone Number*
E-mail*
example@example.com
Course Intent *
The Insurance Premium Discount Course is the only course that qualifies for the insurance discount unless you have your auto insurance with us, Diversified Insurance. If not, you will need to sign up for a separate class.
I, the undersigned student, agree to participate in the course described above, which consists of one 6-hour class, totaling 6 hours of instruction provided by the driver improvement school mentioned above. I understand that Diversified Insurance is certified by the Georgia Department of Driver Services (DDS) in accordance with Georgia Law Title 40-5-80 (Driver Improvement Act) and the rules and regulations adopted therein. Additionally, I acknowledge that each instructor is certified by the DDS. This course is approved by the DDS.*

I agree
Successful completion of the course listed above requires compliance with each of the following:

1. Attend all classes while sober and free from illicit drugs.

2. Arrive on time for class and return promptly after lunch. Doors will be locked at 8:00 AM and 12:00 PM. For remote classes, you will not be permitted to join the session after 3 PM. Late entry will NOT be allowed (rule set by DDS).

3. Show reasonable attentiveness and participate actively.

4. Attend all sessions unless excused for medical or military reasons (written excuse required).

5. Classes must be completed within 60 days if taken on multiple days.

6. Pass a written or oral examination with a minimum grade of 70 for successful completion.

7. In the event of inclement weather or situations beyond our control, classes may need to be rescheduled. You will have the opportunity to reschedule for any available date. Please note that no refunds will be issued.
Diversified Insurance Driving School does not provide refunds for tuition once the course has been conducted and fulfilled as outlined in this contract. By signing this agreement, I acknowledge that failure to comply with its terms and conditions constitutes a breach of contract. In such cases, the school is not obligated to fulfill the terms of the agreement and reserves the right to terminate the contract immediately at its discretion.*

I agree
It is understood that neither the owner, instructor, nor employee of this school will imply to a student that upon completing their instruction/course, the school guarantees the acquisition of a driver's license for operating a motor vehicle. However, upon successful completion of the course mentioned above, the school will properly issue a certification of completion to the student.

The school maintains a performance bond of ten thousand dollars ($10,000.00) to protect the contractual rights of the students. This bond is written by a company authorized to conduct business in the state of Georgia and will be upheld.

This agreement serves as the contract between the driver improvement school and the student listed above. No verbal statements will be recognized.
Signature of student*

Powered by Jotform SignClear
Date

MonthDayYear
Date

My Products*

Court ordered (Other) Defensive Driving Course $95. (includes 4.74% processing fee. ALL COURSES ARE NON-REFUNDABLE)

$99.50

Driver’s License Reinstatement Course $95. (includes 4.74% processing fee. ALL COURSES ARE NON-REFUNDABLE)

$99.50

Points Reduction Course $95 (includes 4.74% processing fee. ALL COURSES ARE NON-REFUNDABLE)

$99.50

Insurance Discount Course $95 (includes 4.74% processing fee. ALL COURSES ARE NON-REFUNDABLE) $20 off if you have insurance with my agency, Diversified Insurance. Please call 404-669-6941 ext 3 for code

$99.50

Enter coupon

Total

$0.00

NO REFUNDS (PLEASE READ)

Please double-check that you are registering for the correct course. All available options are related to Defensive Driving. Once you select and pay for a course, no refunds will be issued if you later realize it was not the class you intended to take.
You will receive an immediate notification with class details upon submitting this contract.

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

The school is located inside Diversified Insurance, LLC 2896 N Expressway, Suite A, Griffin, GA 30223

Contract - State-Certified Defensive Driving School #DI002371

NO REFUNDS (PLEASE READ)

You will receive an immediate notification with class details upon submitting this contract.