Insurance Liability Declination Form

INSURANCE LIABILITY DECLINATION FORM

This Insurance Liability Declination Form documents the voluntary decision of the undersigned to decline specified liability insurance coverage that is available to the Applicant/Insured. By signing below, the Applicant acknowledges having been offered liability coverage, having received notice of potential risks and financial responsibilities, and understanding the consequences set forth in the certification and hold-harmless provisions in this document.

Applicant / Insured Information

Date of Birth:    Contact Phone:    Email:

Policy Details

General Liability    Auto Liability    Professional Liability (E&O)    Property Damage    Other:

Coverage Limit:    Deductible:    Premium:

Policy Period Start:    Policy Period End:

Coverage Declination

I, the Applicant named above, having been offered liability insurance coverage described in the Policy Details section, hereby elect to decline the following liability coverage components (check all that apply and initial where indicated):

Bodily Injury Coverage    Initials:

Property Damage Coverage    Initials:

Medical Payments Coverage    Initials:

Legal Defense / Defense Costs    Initials:

Decline All Liability Coverage Listed Above    Initials:

Other specific coverage to be declined:

Exclusions and Acknowledgements

I understand and acknowledge that by declining liability coverage I remain legally responsible for liabilities that would otherwise be covered. I further acknowledge the following standard exclusions that may apply to the policy whether or not coverage was elected:

Applicant represents that the offer of liability coverage was made in compliance with applicable requirements and that the decision to decline is voluntary and not the result of coercion or misrepresentation. Applicant further understands that third parties may not be bound by this declination and that additional contractual or statutory obligations may require proof of coverage.

Alternative Risk Management (if applicable)

If declining coverage in whole or part, indicate alternative means of satisfying liability obligations (select all that apply and provide supporting details):

Self-Insured Retention / Self-Funded    Surety Bond    Contractual Indemnity    Other:

Beneficiary / Payee Designation (If Applicable)

If the declination affects entitlement to any policy proceeds or refunds, designate beneficiary or payee for such funds. If not applicable, write "N/A."

Certification and Hold-Harmless

By signing below, Applicant certifies under penalty of perjury that all information provided on this form is true and complete. Applicant knowingly and voluntarily declines the specified liability coverage and agrees to assume full responsibility for any losses, liabilities, claims, damages, costs, or expenses that would otherwise be covered. Applicant agrees to indemnify, defend and hold harmless the insurer, agent, and any additional insureds from any liability arising from the decision to decline coverage and from obligations that would have been covered by the declined insurance.

Applicant further acknowledges that this declination may be subject to approval or acceptance by the insurer or other contracting parties and that any representations made herein may be relied upon by the insurer or its representatives.

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