Insurance Rejection of Coverages

INSURANCE REJECTION OF COVERAGES

Insured Name:    Policy Number:

Insurer Name:    Agent/Producer:

Policy Period From:   To:

Applicant / Insured Information

Policy Details

Policy Type: Homeowners Auto Life Business/Commercial

Coverages Offered — Election to Reject

The undersigned Insured acknowledges that the insurer offered the coverages listed below. By checking any box in the column "Reject", the undersigned affirmatively and voluntarily declines that specific coverage and accepts the legal consequences described in the Acknowledgment section of this form.

Effect of Rejection — Acknowledgment

By signing below the Insured acknowledges that any coverage declined by checking the corresponding "Reject" box is being affirmatively and voluntarily refused. The Insured understands and agrees that:

1. Any loss or liability that would otherwise be covered by declined coverage will not be paid by the insurer and the Insured retains full financial responsibility for such loss or liability;
2. The insurer and its agents have no obligation to pay claims arising from coverages that have been rejected by the Insured;
3. The rejection of specific coverages may affect other coverages, limits, defenses, or endorsements; any interrelation is set forth in the applicable policy language;
4. The Insured has had the opportunity to review the scope, limits, deductibles, exclusions, and premium impact of each offered coverage;
5. The Insured is advised that rejection of coverage may increase out-of-pocket exposure and, in some circumstances, may affect the availability of coverage in future underwriting evaluations.

Effective Date of Rejection:    Estimated Premium Change:

Exclusions and Important Notices

The Insured acknowledges receipt of a summary of principal exclusions applicable to the policy. Common exclusions may include intentional acts, wear and tear, war, nuclear hazard, and certain professional liabilities. This Rejection of Coverages does not modify the policy except as to those coverages affirmatively rejected and as expressly documented in the insurer's policy endorsements and declarations.

I acknowledge that I have received and reviewed the summary of principal exclusions applicable to the offered policy.

Beneficiary Information (if applicable)

Declaration and Certification

I, the undersigned Insured, declare under penalty of perjury that I am the named insured or an authorized representative with authority to bind the named insured. I certify that I have read this Insurance Rejection of Coverages form, that the information provided is true and correct to the best of my knowledge, and that my decision to reject any offered coverage is made freely and voluntarily. I understand that this form will be attached to and become part of the policy declarations and that the insurer will rely upon this form in effecting coverage limits and endorsements.

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