Authorizes caregivers to transport the client in a named vehicle, with insurance and release details.
About 5 minutesClients & vehicle owners
Authorization & Release to Drive Vehicle
Step 1 of 3Authorization
Authorization
request that and hereby authorize Golden Grace Health Care LLC and its Affiliates transport CLIENT as a passenger in the automobile, described as follows:
Vehicle owner & insurance
Release
Owner of automobile described above represents that the automobile is properly licensed, registered, inspected and in safe and operational condition. Further, Owner represents that employees of Golden Grace Health Care LLC and its Affiliates are covered by the insurance policy listed above.
Owner further agrees to release Golden Grace Health Care LLC its owners, affiliates, subsidiaries, and employees from any liability in case of an accident or injury while transporting CLIENT or while performing work for CLIENT in the above-listed automobile.
Client, Client’s Legal Representative or Owner of automobile agrees to notify Golden Grace Health Care LLC and its Affiliates in the event a substitute vehicle is used: and further agrees that the provisions contained herein shall apply to all automobiles substituted.
Client/Legal Representative Signature *
By signing, you agree this electronic signature is the legal equivalent of your handwritten signature.
Automobile Owner Signature *
By signing, you agree this electronic signature is the legal equivalent of your handwritten signature.
Golden Grace Health Care LLC Representative Signature
By signing, you agree this electronic signature is the legal equivalent of your handwritten signature.
