Can this form be signed electronically?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states when intent, consent, attribution, and retention are met.

Is notarization required?

Not typically for administrative exclusions, but some states or employers may require notarization for certain authorizations; verify state rules and policy requirements first.

Who must sign the form?

The approving manager or authorized official signs to authorize exclusion; the driver should receive notice and sign an acknowledgment when required by policy.

How long must the form be retained?

Retain per applicable rules: IRS 3 years, HIPAA 6 years for PHI, and longer where state law or industry practice requires it; consult counsel for specificity.

How do I revoke an exclusion?

Document a formal reinstatement decision with the same level of approval and sign a revocation or reinstatement addendum to the original form.

What if a field is filled incorrectly?

Correct errors with an addendum or corrected form signed by approver; preserve original plus correction to maintain auditability and chain of custody.

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Excluded Drivers Authorization Form

Excluded Drivers Authorization Form

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EXCLUDED DRIVERS AUTHORIZATION FORM

RECITALS

WHEREAS, the Insured Company: (hereinafter "Company") maintains an insurance policy identified as Policy Number: ;

WHEREAS, the Company requires formal written authorization to exclude certain individuals from operation of covered vehicles for the purposes of underwriting, claims handling, or risk management; and

WHEREAS, the undersigned parties desire to document the exclusion of specified drivers in accordance with the terms and conditions set forth herein, effective as of the Effective Date: Month Day Year .

EXCLUSION DETAILS

List of Excluded Drivers (complete one entry per individual)

1. Full legal name Date of birth Driver's license number and state Reason(s) for exclusion Exclusion effective period (start — end) Start: Month Day Year End: Month Day Year

2. Full legal name Date of birth Driver's license number and state Reason(s) for exclusion Exclusion effective period (start — end) Start: Month Day Year End: Month Day Year

Additional drivers (if more than two): please attach a completed continuation sheet signed by the authorized Company representative.

SCOPE OF EXCLUSION

The excluded driver(s) identified above shall be prohibited from operating any vehicle insured under the referenced policy for business purposes described below. Describe operational limitations, vehicle classes, or locations affected by this exclusion:

PAYMENT TERMS

Administrative fee for processing exclusion (if applicable): $

Payment schedule and method:

Late payment charge:

TERM AND TERMINATION

Term commencement date: Month Day Year .

Term expiration date: Month Day Year .

Either party may terminate this authorization for any reason upon written notice to the other party delivered at least days prior to the intended termination date. Termination shall not affect obligations incurred prior to the effective date of termination.

CONFIDENTIALITY

The parties acknowledge that certain information exchanged in connection with this exclusion may be confidential. Each party agrees to hold confidential information in strict confidence and to use such information solely for purposes of implementing and enforcing this authorization. Confidential information shall not include information that is or becomes publicly available through no breach of this agreement, or is required to be disclosed by law, provided the disclosing party gives prompt notice and cooperates in any protective measures.

GOVERNING LAW

This Authorization shall be governed by and construed in accordance with the laws of the State of , without regard to its conflict of laws principles.

ENTIRE AGREEMENT

This Authorization constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations, and understandings, whether written or oral. Any amendment or modification must be in writing and signed by both parties.

AUTHORIZATION AND CERTIFICATION

The undersigned Company representative certifies that they are duly authorized to execute this Authorization on behalf of the Company and that the information supplied herein is true and complete to the best of their knowledge. The excluded driver(s) (where signature is provided) acknowledge receipt of notice of exclusion and understand the operational limitations imposed by this Authorization.

Authorized Company Representative - Print name Title Contact phone / email

Authorized Representative:

By:

Date:

Excluded Driver:

Signature:

Date:

What the Excluded Drivers Authorization Form Is

The Excluded Drivers Authorization Form documents an employer, fleet manager, insurer, or program administrator's decision to exclude a named individual from driving certain vehicles or operating under a specific policy. It records the identity of the excluded driver, the factual or investigatory basis for the exclusion, the effective and review dates, and any conditions for reinstatement. The form creates an auditable record used by safety, risk, and compliance teams and may be required for insurance claims, internal discipline, or regulatory reporting when an organization restricts driver privileges.

Why this Form Matters for Risk and Compliance

Using a formal Excluded Drivers Authorization Form centralizes decisions, preserves evidence, and supports consistent handling across drivers and locations. It reduces ambiguity for insurance underwriters and legal teams, and helps demonstrate a documented safety process in audits or claims.

Who Completes and Reviews the Form

Typical users complete, approve, and retain the Excluded Drivers Authorization Form as part of safety and claims workflows.

Fleet Safety Managers who assess driving records, incidents, and fitness to drive and who enforce temporary or permanent exclusions.
Human Resources or Employee Relations who apply disciplinary policies and coordinate return-to-work or retraining conditions.
Insurance Risk Analysts who need documented exclusions to support policy terms, premium adjustments, or claim responses.

The completed form should be routed to HR, risk management, and the insurance administrator; access restricted per privacy requirements.

Step-by-Step: Completing the Form

Follow these steps in order to ensure the form is complete, consistent, and legally defensible.

01

Collect identity: Verify full legal name and license number.
02

Document facts: Record incident details, dates, and evidence.
03

Define scope: Specify vehicle classes and operational limits.
04

Authorize and store: Get signed approval and file securely.

Typical Operational Workflow

A typical process routes the form from incident intake through approval to secure retention; each step captures actions and timestamps.

Incident Intake: Safety team logs the event and requests the form.
Investigation: Collect witness statements, telematics, and citations.
Decision: Authorized manager completes and signs the form.
Notification: Inform payroll, HR, insurance, and the driver.

Configuring an Online Workflow

Set up fields, signer roles, and routing to match internal approvals and retention rules.

Field	Configuration
Signer Roles	Assign driver, manager, safety officer
Authentication	Email + optional SMS code
Conditional Fields	Show reinstatement conditions after approval
Retention Policy	Auto-archive per retention timeline

Platform and Integration Considerations

Choose a signing platform that supports secure identity, audit trails, and your records-retention needs.

File formats: PDF, DOCX supported
Integrations: Salesforce, NetSuite, Microsoft 365
Authentication: Email, SMS, KBA options

Confirm the platform provides encryption, audit logs, and any required compliance (HIPAA BAA if medical data is included).

Timelines and Typical Processing Expectations

Processing times and deadlines vary by organization; establish clear SLAs for investigation, approval, and review.

Initial Acknowledgment:

Acknowledge receipt within 2 business days.

Investigation Window:

Complete fact-finding within 7–14 days.

Decision Notice:

Notify the driver within 3 business days of decision.

Mandatory Review:

Schedule reinstatement review within 90 days when conditional.

Record Update:

Update HR and insurance records within 5 business days.

Penalties and Risks of an Incorrect or Missing Form

Insurance denial: Possible claim denial or surcharge

Regulatory exposure: Fines or citations from regulators

Liability increase: Greater legal risk after incidents

Employment disputes: Grievances or wrongful termination claims

Data breaches: Privacy penalties if mishandled

Reputational harm: Trust and vendor impacts

Security and Compliance Essentials

Encryption: AES-256 at rest

Transport: TLS 1.2/1.3 in transit

Audit Trail: Timestamped signer events

HIPAA: BAA required for PHI

ESIGN/UETA: Legal e-signature compliance

Access Controls: Role-based permissions

Common Preparation Mistakes to Avoid

Using informal language that fails to identify scope or conditions, which creates ambiguity during appeals or insurance reviews.
Entering inconsistent identity details (name, license number, DOB) that impede background checks and tie-breaking across systems.
Failing to attach supporting evidence such as incident reports, citations, or telematics data, weakening the exclusion justification.
Not applying appropriate privacy controls when the form contains medical or sensitive personal information, risking HIPAA or state privacy issues.

Key Components of a Professional Excluded Drivers Form

A well-structured form collects identity, incident facts, scope, approvals, and review mechanics while linking to evidence and policy references.

Driver Identity

Full legal name, license number, state of issuance, and contact details for unambiguous identification and verification.

Incident Summary

Concise factual description of the events, dates, locations, witnesses, and any citations or enforcement actions taken.

Scope and Duration

Precise limits on vehicles, routes, tasks, and the effective date plus any scheduled review or expiration date.

Evidence Links

Reference to attached documents, telematics reports, photos, and police reports for reproducible audit trails.

Approval Block

Name, title, signature, and date of the approver; includes space for secondary reviewer or legal counsel if needed.

Reinstatement Criteria

Clear, measurable steps for return to driving, such as training, medical clearance, or time-based probation conditions.

eSignature Vendor Comparison Relevant to This Form

Platform choice affects cost, compliance options, and envelope limits; signNow is listed first for comparison consistency.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Practical Examples of Use

These examples show how organizations document exclusions and use secure signing to maintain compliance.

Property Management Example

A property manager documents a contractor driver's suspension after an incident using a structured exclusion form

Evidence attached includes incident photos and insurer notice
That company then stored the signed form and attachments in a secure eSignature system to support an insurance claim and internal audit.

Enterprise Fleet Example

A small fleet applied the form after a citation to restrict a driver from overnight deliveries

The form recorded scope and review date
The fleet cited its standardized process and preserved audit logs to satisfy internal compliance and to inform insurer discussions.

Frequently Asked Questions

Answers to common questions about signing, validity, and recordkeeping for the Excluded Drivers Authorization Form.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states when intent, consent, attribution, and retention are met.
Is notarization required?
Not typically for administrative exclusions, but some states or employers may require notarization for certain authorizations; verify state rules and policy requirements first.
Who must sign the form?
The approving manager or authorized official signs to authorize exclusion; the driver should receive notice and sign an acknowledgment when required by policy.
How long must the form be retained?
Retain per applicable rules: IRS 3 years, HIPAA 6 years for PHI, and longer where state law or industry practice requires it; consult counsel for specificity.
How do I revoke an exclusion?
Document a formal reinstatement decision with the same level of approval and sign a revocation or reinstatement addendum to the original form.
What if a field is filled incorrectly?
Correct errors with an addendum or corrected form signed by approver; preserve original plus correction to maintain auditability and chain of custody.

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