Insurance Accident Waiver

Insurance Accident Waiver

Applicant / Insured Information

Policy Details

Accident Details

Date of Accident:

Time of Accident:

Coverage Sections (select all that apply)

Bodily Injury Liability

Property Damage Liability

Uninsured/Underinsured Motorist

Medical Payments

Collision

Comprehensive

Exclusions (Acknowledgment required)

The insured acknowledges that the policy may exclude coverage for certain causes and circumstances. By initialing and checking the applicable boxes below the insured affirms understanding of these exclusions.

Accidents arising from operation while under the influence of alcohol or controlled substances.

Intentional acts, including intentionally self-inflicted injury or willful misconduct.

Failure to report the loss to the insurer within the time required by the policy.

Use of the insured vehicle for commercial hire or delivery where policy prohibits such use.

Release, Waiver and Subrogation

For and in consideration of the policy benefits described above and other valuable consideration, the undersigned Insured hereby knowingly and voluntarily executes this Insurance Accident Waiver as follows:

1. Waiver of Subrogation: The Insured waives any right of recovery, claim, or cause of action against any third party specified below to the extent of any sums paid by the Insurer under the policy for losses arising from the incident described in this form. The Insured further agrees to execute any further instruments reasonably required by the Insurer to effectuate this waiver.

2. Broad Release: The Insured releases and discharges the Releasees from all claims for bodily injury, property damage, economic loss, and other liabilities arising out of the accident identified herein to the extent of recoveries provided by the Policy and as further limited by this Waiver.

3. Reservation of Rights: Nothing in this Waiver obligates the Insurer to provide coverage beyond the express terms, limits, conditions, and exclusions of the Policy. The Insurer reserves all defenses and coverage determinations under the Policy.

Indemnity and Cooperation

The Insured agrees to indemnify and hold harmless the Releasees for any damages, costs, or expenses arising from claims that exceed policy limits caused by misrepresentation, fraud, or failure to cooperate. The Insured shall cooperate fully with the Insurer and any Releasee in the investigation, defense, or settlement of any claim, including providing statements, documents, and access to the scene or property.

Beneficiary Designation (If Applicable)

If policy proceeds are payable to a beneficiary in connection with this claim, identify the beneficiary below. If no beneficiary applies, enter "Not Applicable."

Claim Notification and Documentation

The Insured must promptly notify the Insurer of any claim, provide all requested documentation, and preserve any physical evidence. Failure to provide timely notice or requested documentation may prejudice coverage and the effectiveness of this Waiver.

Representations and Certification

By signing below, the Insured represents and certifies that: (a) all information provided in this Waiver and accompanying documentation is true and complete to the best of the Insured's knowledge; (b) the Insured has read and understands the terms of this Waiver, including the waiver of subrogation and release provisions; and (c) the Insured is authorized to enter into this Waiver and to bind any named insureds or beneficiaries.

The Insured acknowledges that this Waiver may affect the Insured's legal rights, including the ability to pursue certain claims against third parties, and that the Insured has had the opportunity to seek independent legal advice prior to signing.

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