Insurance Coverage Waiver

INSURANCE COVERAGE WAIVER

This Insurance Coverage Waiver documents the voluntary relinquishment by the Insured of certain coverages under the insurance policy identified below. The insured affirms that the selections and acknowledgements below are made knowingly, voluntarily, and with full understanding of the consequences. Insurer Name: Policy Number:

Insured / Applicant Information

Date of Birth: Telephone: Email:

Policy Details

Policy Period Start: End:

Waiver of Coverage (Select all coverages to be waived)

Liability Coverage (Bodily Injury / Property Damage)

Collision Coverage

Comprehensive Coverage

Personal Injury Protection / Medical Payments

Uninsured / Underinsured Motorist Coverage

Coverage Acknowledgements and Consequences

By selecting any waiver above and signing below, the Insured acknowledges and agrees to the following statements:

1. Voluntary Waiver: The Insured knowingly and voluntarily waives the selected coverage(s) and understands that this waiver reduces or eliminates the insurer's obligation to pay claims otherwise covered under the policy for the waived coverage(s).
2. Assumption of Risk: The Insured assumes full financial responsibility for losses, damages, injuries, or liabilities that would have been covered by the waived coverage(s), including third-party claims and legal costs arising from those events.
3. No Contraints: The insurer has not coerced or conditioned other coverage or policy issuance upon the Insured's execution of this waiver. The Insured confirms sufficient time and opportunity to consider this waiver.
4. Effect on Claims: The Insured understands that claims for losses arising during the policy period for waived coverage(s) may be denied, limited, or subject to reduced recovery, and that statutory or regulatory minimum financial responsibility requirements remain the Insured's obligation where applicable.

Initial to acknowledge each statement:

Exclusions

The following standard policy exclusions remain applicable and are not altered by this Waiver. Examples include intentional acts, fraud, criminal acts, wear and tear, and damage arising from unreported or uninsured use. Additional exclusions or endorsements specific to this policy:

Beneficiary Designation (if applicable)

The Insured designates the following beneficiary(ies) for any proceeds payable as a consequence of covered events not affected by this waiver. Beneficiary 1 Name:

Relationship: Percentage:

Beneficiary 2 Name:

Relationship: Percentage:

Certification and Release

I, the undersigned Insured, certify that the information provided in this Waiver is true and correct to the best of my knowledge. I acknowledge that by executing this Waiver I am releasing, to the extent permitted by law, the Insurer from liability for claims that would otherwise be covered by the waived coverage(s). I further agree to indemnify and hold the Insurer harmless from any claims, losses, or expenses arising solely as a result of my election to waive coverage, except where the Insurer's conduct constitutes willful misconduct or breaches of the policy's express terms.

I understand that this Waiver may affect rights of third parties and may affect my compliance with statutory financial responsibility requirements. I have had an opportunity to ask questions and have received adequate answers concerning the consequences of this Waiver.

Acknowledgement of truthfulness (print name and sign below constitutes certification under penalty of perjury where applicable).

Administrative Use

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