Diocese of San Diego
Pastoral Center
For our records: Please fill out and return this form to Human Resources Dept.
Name: Date:
Office: Cell # :
Driver’s License No. State
PERSONAL AUTO INSURANCE POLICY:
Carrier’s Name: Policy No.
Expiration Date:
AUTOMOBILE #1 INFORMATION AUTOMOBILE #2 INFORMATION
Add □ Remove □ Add □ Remove □
Make: Model: Make: Model:
Year: Lic.#: Year: Lic.#:
State: Color: State: Color:
EMERGENCY CONTACT INFORMATION:
Contact Name:
Relationship:
Contact Address:
Contact Phone:
Auto. 01/08