Insurance Liability Waiver Form

INSURANCE LIABILITY WAIVER FORM

This Insurance Liability Waiver Form (the "Waiver") documents the Applicant's voluntary assumption of risk, release of liability, and certain limitations of coverage with respect to the policy identified below. Applicant acknowledges that execution of this Waiver is a material condition of coverage, consideration for underwriting, or in connection with provision of certain services or benefits by the Insurer and agrees to be bound by the terms set forth herein.

Applicant / Insured Information

Policy Details

Policy Period (To):

Coverage Selections

Select the coverage components to which this Waiver applies. If no box is checked, the Waiver shall apply to the full policy as issued.

Waiver and Release

In consideration of the Insurer's agreement to issue, renew, modify, or continue insurance coverage, and other good and valuable consideration, Applicant hereby irrevocably and unconditionally agrees as follows:

1. Assumption of Risk: Applicant acknowledges that participation in or exposure to the insured activity, property, or operations described as involves inherent risks, including bodily injury, property damage, and economic loss. Applicant voluntarily assumes all such risks.

2. Release and Waiver: Applicant, on behalf of Applicant and Applicant's heirs, executors, administrators, agents and assigns, releases, waives and discharges the Insurer, its agents, representatives, officers and employees (collectively, "Released Parties") from any and all claims, demands, causes of action, suits, or liabilities for loss, damage, injury, or death that arise out of or relate to the covered risks, except to the extent such liability is the result of the Released Parties' gross negligence or willful misconduct.

3. Indemnification and Hold Harmless: Applicant agrees to indemnify, defend and hold harmless the Released Parties from and against any and all losses, damages, liabilities, costs and expenses (including reasonable attorney fees) arising from third-party claims asserted against the Released Parties to the extent attributable to Applicant's acts or omissions, including breach of this Waiver.

4. Waiver of Subrogation and Assignment: Applicant expressly waives any right of subrogation, reimbursement, or assignment against the Released Parties for amounts paid under the policy in relation to the risks addressed by this Waiver. Applicant will not assign any claim subject to this Waiver without the prior written consent of the Insurer.

5. Continuing Effect; Amendment: This Waiver shall be effective with respect to any claims arising during the Policy Period identified above and shall survive the expiration or termination of the policy to which it relates. This Waiver may be amended only by a written instrument signed by Applicant and an authorized representative of the Insurer.

6. Representations and Reliance: Applicant represents that all statements and information provided to the Insurer or its agent in connection with the policy and this Waiver are true, accurate and complete. Applicant understands that material misrepresentation may result in rescission of coverage or denial of claims as permitted by law and policy terms.

7. Governing Law and Venue: This Waiver shall be governed by and construed in accordance with the substantive laws of the state of without regard to its choice-of-law rules. Applicant consents to the exclusive jurisdiction and venue of the courts located within that state for any dispute arising out of this Waiver.

Exclusions

This Waiver does not apply to: (a) claims arising from gross negligence or willful misconduct by the Released Parties; (b) claims covered under Workers' Compensation or similar statutory benefits; (c) criminal acts or intentional torts committed by the Released Parties; or (d) loss excluded by specific policy terms such as nuclear hazard, war, or other perils expressly excluded in the policy.

Exposure / Incident Description

Beneficiary Designation (If Applicable)

Designate primary beneficiary(ies) who shall receive any payable benefits under the policy in the event of Applicant's death, if applicable to the policy type.

Acknowledgment and Certification

By signing below, Applicant certifies under penalty of perjury that the information provided in this Waiver is true and complete to the best of Applicant's knowledge; Applicant has read and understands this Waiver; Applicant knowingly and voluntarily accepts the rights being waived and the obligations assumed herein; and Applicant has authority to execute this Waiver on behalf of the named insured if signing in a representative capacity.

Sign Now