Insurance Rejection of Coverage Form

Insurance Rejection of Coverage Form

Insurer Name:     Branch/Agent:

Applicant / Insured Information

Policy Details

Offered Coverages — Applicant Selection

The applicant acknowledges that the following coverages were offered and elects to reject the coverage items checked below. Rejection is a voluntary relinquishment of coverage and may affect the applicant's rights and financial exposure.

Exclusions and Consequences of Rejection

By rejecting any coverage above, the applicant expressly understands and agrees that the insurer will have no obligation to provide the rejected coverage for any claims, losses, or liabilities that would otherwise be covered. The applicant accepts full financial responsibility for losses that would have been covered by the rejected coverage and understands that this rejection may limit recovery in the event of a loss.

Standard policy exclusions continue to apply to all remaining coverages, including but not limited to intentional acts, non-permitted uses, wear and tear, and losses excluded by endorsement. The applicant acknowledges receipt of a list of standard exclusions and has had the opportunity to review them.

Initial to acknowledge you have read and understand the exclusions and consequences of rejecting coverage:

Beneficiary Information (if applicable)

If rejection affects death benefit or similar coverages, indicate beneficiary information below. If not applicable, leave blank.

Declaration and Applicant Certification

I, the undersigned applicant, certify that the information provided on this form is true and complete to the best of my knowledge. I understand that by rejecting the coverage items checked above I may be exposed to financial loss that would otherwise be covered by the rejected coverage. I knowingly, voluntarily, and intentionally decline the checked coverage(s).

I release and hold harmless the insurer, its agents, and representatives from any claim arising solely from the applicant's election to reject the coverage(s) indicated above, except to the extent the insurer's acts or omissions constitute gross negligence or willful misconduct as defined by applicable law.

I acknowledge that premium adjustments, if any, resulting from this rejection have been explained to me and that I have been given the opportunity to accept or decline the adjusted premium. I understand that reinstatement of rejected coverage may require underwriting approval and a signed written request.

Applicant confirms the foregoing by checking the box below and signing at the end of this form.

I acknowledge and accept the terms of this Rejection of Coverage.

For Insurer Use Only

Action taken by insurer (check one): Accepted Pending review Declined

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