Insurance Refusal Form

INSURANCE REFUSAL FORM

Use this form to document the insured's voluntary declination, refusal, or waiver of specific insurance coverage or policy features offered by the insurer or agent. Completion of this form creates a record that the insured was informed of the coverage, the cost, and the consequences of refusal and that the insured knowingly and intentionally declined the coverage described below.

APPLICANT / INSURED INFORMATION

POLICY AND OFFER DETAILS

Insurer:    Agent / Broker:

Policy Number:    Policy Type:

Coverage Limit Offered: $    Deductible: $    Premium: $

Policy Period: From to

COVERAGE(S) DECLINED

I hereby decline the following coverage(s) or policy feature(s) that were offered to me (check all that apply):

Collision Coverage / Comprehensive

Uninsured / Underinsured Motorist Coverage

Medical Payments / Personal Injury Protection

Rental Reimbursement / Loss of Use

Roadside Assistance / Towing

Increase in Liability Limits

Other (specify below)

REASONS FOR REFUSAL

Select the primary reason(s) for declining coverage (check all that apply):

Cost / Premium is unaffordable

Coverage is not needed / not applicable

Already covered under another policy

Personal / religious objection

Other (explain below)

BENEFICIARY INFORMATION (IF APPLICABLE)

Beneficiary Name:    Relationship:

Percentage Allocated: %

EXCLUSIONS AND EFFECT OF REFUSAL

The following categories of loss are excluded from coverage unless explicitly included in a binding policy: intentional or criminal acts by the insured, losses arising from use of the insured property in a prohibited or racing activity, nuclear hazard, war or invasion, punitive damages to the extent excluded by law, and any other exclusion set forth in the policy contract. By declining coverage, the insured acknowledges that losses falling within the declined coverage will not be paid by the insurer and the insured will retain full financial responsibility for such losses.

I acknowledge that I have read and understand the exclusions listed above and that I will not have insurance protection for matters excluded or for coverage I have declined.

CERTIFICATION, WAIVER AND INDEMNITY

I certify under penalty of perjury that I am the person named above or an authorized representative of the named insured, that I have been offered the coverage described in this form, that the coverage and cost were explained to me, and that I knowingly and voluntarily decline the coverage(s) checked above. I understand that by refusing coverage I may be personally liable for losses that would otherwise have been covered.

I further agree to indemnify and hold harmless the insurer, its agents, and representatives from any claims, damages, or expenses arising from my refusal of coverage, except to the extent caused by the insurer's bad faith or willful misconduct. This waiver and indemnity survive termination or expiration of any related policy.

Initials to confirm understanding:

OFFER AND NOTICE

I acknowledge that the coverage offered and the consequences of refusing coverage were explained to me by the agent named above on .

I acknowledge receipt of a copy of this signed refusal form: Yes

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