Insurance Policy Rejection Acknowledgment

INSURANCE POLICY REJECTION ACKNOWLEDGMENT

Applicant / Insured Information

Date of birth:

Policy Offered Summary

Policy type:

Coverage amount: $     Deductible: $

Premium: $

Policy effective date:

Policy expiration date:

Coverage Rejection

I hereby acknowledge that I have been offered the coverages described above and choose to reject coverage as follows. Mark all options that apply:

I reject the entire policy offer and decline all coverages described in the policy summary.

Reject Liability coverage

Reject Collision coverage

Reject Comprehensive coverage

Reject Personal Injury Protection

Reject Uninsured/Underinsured Motorist coverage

Reason for Rejection

Acknowledgments, Consequences and Refunds

By signing below, I certify that the insurer or its authorized representative explained the nature, scope and limitations of the offered coverage, any material exclusions, the applicable premium and any deductible. I understand that rejecting coverage may leave me personally responsible for losses or liabilities that would otherwise have been covered. I acknowledge that the insurer is not liable for losses occurring after the effective date for which coverage is rejected.

I understand that if any premium was collected in connection with the offered policy, the insurer will process any applicable refund in accordance with its policy and contractual terms. I further acknowledge that I may forfeit certain rights or discounts by rejecting coverage and that rejection of coverage is voluntary and made without coercion.

I acknowledge that I may forfeit rights to coverage, benefits, or discounts by this rejection.

I acknowledge that this rejection is voluntary and not the result of coercion, misrepresentation, or omission by the insurer or its representative.

Beneficiary Information (If Applicable)

If this policy pertains to life or similar benefits and you wish to record a beneficiary despite rejecting the policy, provide beneficiary details below. If not applicable, check the box below.

Beneficiary information not applicable

Exclusions and Notices

The insurer provided the applicant with a written summary of material exclusions applicable to the offered policy. Material exclusions may include, without limitation, losses due to intentional acts, preexisting conditions, specified perils excluded by endorsement, or statutory exclusions required by law. The applicant acknowledges receipt of that summary or hereby declines to accept the policy notwithstanding such exclusions.

Certification

I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. I understand that signing this form constitutes an official rejection of coverage as indicated above and that such rejection may be relied upon by the insurer.

Did an authorized representative explain the options available prior to rejection? Yes No

Sign Now