Legal Coverage Rejection Form

LEGAL COVERAGE REJECTION FORM

This Legal Coverage Rejection Form is executed as of by and between Legal Coverage Provider Name: (the "Provider") and Client Name: (the "Client").

RECITALS

WHEREAS, Provider maintains or administers a legal coverage program providing specified legal services or benefits to eligible persons or entities subject to the terms of program materials and the Provider's policies; and

WHEREAS, Provider or its agent presented to Client an offer of legal coverage or enrollment in the program identified below, including notification of the scope, limitations, and material conditions of such coverage; and

WHEREAS, Client has reviewed the offer and has been afforded the opportunity to ask questions, seek clarification, and consult independent counsel prior to making an informed election regarding acceptance or rejection of legal coverage.

NOW, THEREFORE, in consideration of the mutual covenants and acknowledgements contained herein, and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Form, "Coverage" means the legal services, benefits, or representation described in the Provider's program materials or offer; "Offer Date" means the date the coverage was offered, identified below; and "Specified Matters" means particular legal matters described by Client as excluded from coverage by this rejection.

2. OFFER IDENTIFICATION

Month Day Year

3. ACKNOWLEDGMENT OF OFFER AND REJECTION

Client expressly acknowledges receipt of the coverage offer identified above and confirms that Provider made material disclosures regarding the scope, limitations, exclusions, costs, and effective dates associated with such coverage. Client further acknowledges that Client has the right to accept or reject the offered coverage and that this Form constitutes a formal, written rejection when executed by both parties.

I hereby reject the offered coverage in its entirety.
I hereby reject coverage only for specified matters (listed below).
I reject Provider-appointed legal representation but reserve other program administrative benefits.

4. WAIVER, RELEASE, AND ASSUMPTION OF RISK

By executing this Form, Client knowingly and voluntarily waives, releases, and forever discharges Provider, its affiliates, agents, contractors, and representatives from any and all claims, causes of action, liabilities, losses, or damages (including costs and attorneys' fees) that arise from or relate to Client's decision to reject the offered coverage, to the extent such claims arise from the scope of the coverage rejected. This waiver and release shall not waive claims arising from Provider's gross negligence or willful misconduct.

5. EFFECT OF REJECTION

Client understands that rejection may preclude access to legal representation, cost coverage, or other program benefits for matters covered by the offer. Client further acknowledges that Provider shall have no obligation to provide services or to pay fees for matters expressly rejected herein, and that any future request for enrollment or reinstatement of coverage will be governed by Provider's then-applicable enrollment policies.

6. CERTIFICATION OF UNDERSTANDING

Client certifies that Client has had the opportunity to review the terms of the offer, ask questions, and consult with independent legal counsel prior to signing. Client further certifies that the rejection is made freely, without coercion, and with full understanding of the consequences described in this Form.

Yes    No

7. NOTICES

Any notice required or permitted under this Form shall be in writing and delivered to the addresses provided below by hand delivery, nationally recognized overnight courier, or certified mail, return receipt requested, and shall be effective upon receipt.

8. GOVERNING LAW; VENUE

This Form shall be governed by and construed in accordance with the substantive laws of the State identified below without regard to conflict of laws principles. The parties consent to exclusive jurisdiction and venue in the courts located in the county indicated below for any dispute arising out of this Form.

9. ENTIRE AGREEMENT; SEVERABILITY

This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations, and understandings, whether oral or written. If any provision of this Form is determined to be invalid, illegal, or unenforceable, the remaining provisions shall remain in full force and effect.

10. AMENDMENT; WAIVER

No amendment or waiver of any provision of this Form shall be effective unless in writing and signed by both parties. No failure or delay by either party to exercise any right shall operate as a waiver of that right.

11. COUNTERPARTS; ELECTRONIC SIGNATURES

This Form may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one instrument. Signatures delivered by electronic means shall be treated as original signatures for all purposes and shall be binding upon the parties.

12. REPRESENTATIONS

Each party represents and warrants that it has full authority to enter into this Form; that the person signing on its behalf is duly authorized; and that this Form constitutes a valid and binding obligation enforceable in accordance with its terms.

ADDITIONAL INFORMATION

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