Can this form be signed electronically?

Yes. Electronic signatures that demonstrate intent, consent, attribution, and retention meet ESIGN and UETA requirements (see 15 U.S.C. §7001 and state UETA laws). Ensure consumer disclosures for consumer-facing transactions.

When is notarization required?

Notarization is rarely required for an internal insurance exclusion. If state law or a counterparty requires notarization, follow that state's notary or RON rules; New York follows ESRA rather than UETA.

Who must sign the form?

An authorized insurer representative and an authorized insured signatory or designee should sign. Document titles and authority should be clear to avoid later challenges.

How do I change or remove an exclusion?

Use a formal amendment or reinstatement form with supporting evidence and approvals. Record the effective date and retain both original and amendment for the retention period.

How long before an exclusion affects claims?

The exclusion is effective as of the date listed on the form or the policy endorsement effective date. Clear timing avoids coverage disputes during claims.

What if information is incorrect after signing?

Errata or correction endorsements should be executed and dated. Retain original and corrected versions and document review or approval steps to preserve auditability.

Electronic Signature
Templates
HR
Excluded Drivers Policy Form

Excluded Drivers Policy Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Excluded Drivers Policy Form

Purpose: This form documents the determination and acknowledgement that an employee or applicant is excluded from operating company vehicles or operating a personal vehicle on company business. It records the factual basis for exclusion, the period and scope of the exclusion, and the employee's acknowledgement of the policy, certifications, and authorization for background checks and motor vehicle record review.

Personal Information

Full Legal Name Home Address Phone Number Email Address

Position Information

Job Title Department Reporting Manager Employment Start Date Salary or Pay Rate

Driving Credentials

Driver's License Number

State:

Class:

Expiration:

Exclusion Determination

The following represent company-defined exclusion criteria. Check all that apply and provide supporting details where requested. An exclusion prohibits operation of company vehicles and driving a personal vehicle for company business until reinstatement in writing by the employer.

Exclusion Reason(s) Conviction for driving under the influence (DUI/DWI) within the applicable lookback period License suspended or revoked Medical condition affecting safe operation Excessive moving violations or points Pending criminal charges related to driving Other (describe)

Exclusion Effective Date:

Expected Review Date:

Incident History

Describe Incident(s) That Led To Exclusion

Date of Most Recent Incident:

Location:

Number of At-Fault Accidents (5 yrs):

Employment History (Most Recent)

Employer 1 - Company Name

Title:

From:

To:

Primary Responsibilities Reason for Leaving

Employment History (Prior)

Employer 2 - Company Name

Title:

From:

To:

Primary Responsibilities Reason for Leaving

Education

Highest Degree or Certification Institution Graduation Date

References

Reference 1 Reference 2 Reference 3

Legal Disclosures and Company Policy

Motor Vehicle Record Review: By signing below, I understand that the employer will obtain and review my driving record and other background information to determine eligibility to operate company vehicles or to drive on behalf of the company. The review may include convictions, suspensions, revocations, accidents, and other driving-related information for the period required by company policy.

Privacy and Use of Records: Information collected is used solely for determination of driving privileges and related safety and insurance compliance. The company will retain records for a period consistent with business and legal requirements. Access to these records is limited to authorized personnel.

At-Will Employment and Equal Opportunity: Nothing in this form changes the at-will nature of employment. The company is an equal opportunity employer and will consider reasonable accommodations consistent with applicable law when appropriate.

Duty to Notify: I agree to notify my manager and Human Resources in writing within 24 hours of any change in my license status, any driving-related arrest, citation, suspension, revocation, or medical condition that may affect my ability to drive safely.

Authorization and Certification

I certify under penalty of perjury that the information I have provided on this form is true, complete, and correct to the best of my knowledge. I understand that falsification, omission, or failure to disclose relevant information may result in disciplinary action up to and including termination.

I authorize the company to obtain my motor vehicle record and to conduct any investigatory background checks reasonably related to this determination. I acknowledge receipt of the Excluded Drivers Policy and understand the restrictions imposed by the exclusion. I understand that willful false statements on this form may be grounds for disciplinary action, up to and including termination. Employee Comments (Optional)

Appeals and Review: The employee may request a review of the exclusion decision in writing within the time period specified by company policy. The request will be reviewed in accordance with company procedures; however, the exclusion remains in effect during the review unless otherwise directed by Human Resources.

Employee Name:

Signature:

Date:

What the Excluded Drivers Policy Form Is

The Excluded Drivers Policy Form documents individuals who are excluded from driving coverage under an auto or fleet insurance policy. It typically records the named insured, the drivers excluded by name or by class, the effective date of the exclusion, the reason for exclusion, and any appeal or reinstatement terms. Insurers use this form to adjust underwriting, clarify coverage boundaries, and provide notice to insureds. The form is often attached to the master policy and retained with claims and underwriting files for compliance and audit purposes.

Why This Form Matters for Insurers and Policyholders

An accurate Excluded Drivers Policy Form reduces coverage disputes, clarifies liability exposure, and supports consistent underwriting. It creates a written record that can be relied on during claims handling and regulatory review.

Who Completes and Signs the Form

Typical parties involved include underwriting staff, risk managers, insured business representatives, and claims teams.

Underwriting teams who assess risk and record exclusions for policy issuance or renewal.
Fleet managers or insured representatives who confirm excluded drivers and provide supporting documentation.
Claims adjusters who reference the exclusion when evaluating liability and coverage.

Signatures are usually required from an authorized insurer representative and the named insured or authorized designee to document agreement and acknowledgment.

Core Sections to Include on a Professional Excluded Drivers Policy Form

A complete form groups identification, exclusion details, rationale, and execution elements to avoid ambiguity and support future claims or audits.

Policy Header

Policy number, named insured, insurer name, and effective policy period so the exclusion is linked to the correct policy.

Excluded Parties

Full legal names, dates of birth, and driver license numbers for each excluded person to ensure precise identification.

Scope of Exclusion

Whether the exclusion is complete, limited to business use, or applies only to specific vehicles or locations.

Reason for Exclusion

Concise factual reason (e.g., DUI conviction, license suspension, high-risk driving history) with dates and supporting reference numbers.

Appeal / Reinstatement

Procedures, documentation required, and any waiting periods or remedial steps for removing the exclusion.

Execution

Signature blocks, printed names, titles, and dates for insurer and insured to evidence mutual acknowledgement.

Required Information Fields at a Glance

Driver Name: Full legal name

Date of Birth: MM/DD/YYYY

License Number: State-issued ID

Exclusion Reason: Brief code or phrase

Effective Date: MM/DD/YYYY

Authorized Signature: Insurer and insured

Step-by-Step: Completing the Excluded Drivers Policy Form

Follow this sequence to prepare, review, and record an exclusion correctly.

01

Prepare Record: Collect IDs, DMV records, and any conviction documentation.
02

Complete Fields: Fill identification, reason, effective date, and policy reference.
03

Review Internally: Underwriting or legal reviews the entry for accuracy.
04

Execute: Obtain signatures from insurer and insured; record signed copy.

Customizing the Form and Digital Workflow

Configure template fields, signer order, and authentication to match your compliance and operational requirements.

Field	Configuration
Authentication Method	Email with optional SMS code
Required Fields	Make name, DOB, license, effective date mandatory
Conditional Fields	Show appeal section only if 'Appealable' checked
Retention Setting	Archive signed PDF and audit trail for retention

Where to Send and How the Signed Form Is Processed

After execution, route the form to underwriting and claims systems and retain an audit trail for compliance.

Underwriting File: Attach signed form to policy record within 24–48 hours.
Claims Reference: Claims uses the form to determine driver coverage eligibility.
Document Archive: Store signed PDF and metadata in records system.
Audit Trail: Keep time-stamped evidence of signature actions.

Digital Signing and eSubmission Considerations

Choose authentication and storage options that satisfy ESIGN and UETA for enforceability.

Authentication: Email link, SMS code, or KBA where required
Document Formats: Use PDF or DOCX for consistent archiving
Integrations: Connect to policy admin or claims systems

Ensure retention and access controls align with internal recordkeeping and any applicable regulatory requirements.

Typical Timelines and Processing Expectations

Set clear timelines for delivery, review, and recording to minimize disputes and administrative delays.

Form Delivery:

Provide exclusion notice to insured within policy renewal or endorsement period

Internal Review:

Underwriting should review and approve within 7–14 days

Effective Date:

Typically the date listed on form; default to policy renewal if blank

Appeal Deadline:

Insured often has 30 days to request review or submit evidence

Record Archiving:

Store signed form per retention rules and audit needs

Common Mistakes to Avoid

Incomplete identities: omitting DOB or license state can prevent DMV verification and delay underwriting.
Vague reasons: entering 'unsafe' without details undermines enforceability and complicates claims decisions.
Missing signatures: unsigned exclusions are weak evidence and may be treated as unenforceable by regulators.
Improper retention: failing to keep the signed form and audit trail can cause compliance failures during audits.

Penalties and Risks of Incorrect or Missing Information

Coverage Denial: Claims may be denied

Premium Adjustment: Underwriting recalculation possible

Regulatory Fines: State insurance penalties

Liability Exposure: Company may face litigation

Reputational Harm: Customer disputes and complaints

Data Breach Risk: Improper storage invites penalties

Real-World Examples of Use

These customer examples show how firms record and rely on exclusions in practice.

Optica Ventures — COO

Optica standardized exclusion forms to speed underwriting and reduce disputes.

The team centralized driver records to a single policy file.
As a result, Optica reports fewer coverage disagreements and faster claims intake because exclusions are clear, dated, and digitally archived with an audit trail.

Martin Properties — Founder

Martin Properties moved to digital exclusions for its property-management fleet.

Paper renewals delayed updates for weeks.
Switching to a signed digital form ensured exclusions were applied at renewal, reducing liability exposure and administrative overhead during tenant transitions.

eSignature Pricing and Feature Comparison

Compare common vendor starting prices and select features for executing and storing Excluded Drivers Policy Forms. Pricing models vary by plan and billing term.

	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	Varies by plan	Varies by plan	Varies by plan	Varies by plan

Frequently Asked Questions

Answers to common questions about completing, signing, and enforcing an Excluded Drivers Policy Form.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures that demonstrate intent, consent, attribution, and retention meet ESIGN and UETA requirements (see 15 U.S.C. §7001 and state UETA laws). Ensure consumer disclosures for consumer-facing transactions.
When is notarization required?
Notarization is rarely required for an internal insurance exclusion. If state law or a counterparty requires notarization, follow that state's notary or RON rules; New York follows ESRA rather than UETA.
Who must sign the form?
An authorized insurer representative and an authorized insured signatory or designee should sign. Document titles and authority should be clear to avoid later challenges.
How do I change or remove an exclusion?
Use a formal amendment or reinstatement form with supporting evidence and approvals. Record the effective date and retain both original and amendment for the retention period.
How long before an exclusion affects claims?
The exclusion is effective as of the date listed on the form or the policy endorsement effective date. Clear timing avoids coverage disputes during claims.
What if information is incorrect after signing?
Errata or correction endorsements should be executed and dated. Retain original and corrected versions and document review or approval steps to preserve auditability.

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