Insurance Damage Waiver

INSURANCE DAMAGE WAIVER

Applicant / Insured Information

Policy Type / Coverage Selection

Indicate the policy type(s) to which this waiver applies (select all that apply):

Waiver Terms and Legal Provisions

This Insurance Damage Waiver (the "Waiver") is executed by the undersigned Applicant. In consideration of the insurer's continued issuance or maintenance of the policy identified above and other good and valuable consideration, the Applicant hereby knowingly, voluntarily, and irrevocably agrees as set forth below. Applicant Printed Name:

1. Waiver of Subrogation: Subject to the limitations and exclusions set forth herein, Applicant expressly waives any right of subrogation, recovery, or reimbursement that Applicant, Applicant's insurer, or Applicant's successors or assigns may have against any third party for damages covered by the policy identified above arising out of the matters described in this Waiver.

2. Release of Liability: Applicant releases and forever discharges any party identified in this Waiver from claims for loss, damage, or liability to the extent that such claims would otherwise be subject to subrogation by Applicant's insurer.

3. Indemnification: Applicant shall indemnify and hold harmless the insured parties from and against any liability, loss, cost, or expense (including reasonable attorneys' fees) arising from any claim asserted by Applicant, except to the extent such claim results from the indemnified party's intentional misconduct or gross negligence.

4. Scope of Waiver (select applicable items): The waiver applies to damage or loss involving:

5. Limitations and Exclusions: This Waiver does not apply to claims arising out of (initial to acknowledge):

6. Duration: This Waiver shall be effective as of and shall remain in force for the duration of the policy period specified above unless sooner revoked in writing by the insurer with notice to Applicant.

7. Representations: Applicant represents that Applicant has authority to execute this Waiver on behalf of all persons and entities named as insured under the policy identified above, and that all information provided on this form is true and complete to the best of Applicant's knowledge.

8. Governing Law and Severability: This Waiver shall be governed by the substantive laws of the state indicated below. If any provision of this Waiver is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

Beneficiary Information

Identify the person or entity designated to receive proceeds or recoveries in the event of a successful subrogation claim that is expressly permitted under the policy or this Waiver:

Damage Notice (If Loss Has Occurred)

If the damage or loss has already occurred, provide the following information. If not applicable, indicate "N/A".

Documentation Checklist (select all attached):

Declaration and Certification

I certify under penalty of perjury that the statements made in this Waiver and any attachments are true and complete to the best of my knowledge. I acknowledge that I have read and understand the terms of the Waiver, including the waiver of subrogation and the limitations and exclusions contained herein. I further acknowledge that I have had the opportunity to seek independent legal advice prior to execution of this Waiver.

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