Legal Excluded Driver Form

LEGAL EXCLUDED DRIVER FORM

This Legal Excluded Driver Form is entered into as of Effective Date: by and between Insurer Name: and Insured Name: (collectively, the Parties).

RECITALS

WHEREAS, Insured is the named insured on an automobile insurance policy identified by Policy Number: issued by Insurer; and

WHEREAS, Insured has requested that one or more persons be excluded from coverage under the Policy for the reasons set forth herein; and

WHEREAS, Insurer is willing to record such exclusion(s) on the Policy subject to the terms and conditions of this Form and Insurer's underwriting and issuance procedures.

NOW THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the Parties agree as follows:

1. DEFINITIONS

1.1 "Excluded Driver" means any person identified in the Excluded Drivers Schedule below whose operation of a motor vehicle is expressly excluded from coverage under the Policy as set forth in this Form.

1.2 "Policy" means the automobile insurance policy referenced above, together with any endorsements and schedules issued by Insurer and in effect on the Effective Date.

2. EXCLUSION OF DRIVER(S)

2.1 Subject to the terms of this Form, Insurer records the following person(s) as Excluded Driver(s). While a person is listed as an Excluded Driver, Insurer will not provide any insurance coverage under the Policy for claims arising out of the operation of a motor vehicle by that person, whether as operator or permissive user, including but not limited to liability, medical payments, uninsured/underinsured motorist benefits, and collision or comprehensive coverage as applicable to the Policy.

2.2 Exclusion extends to all motor vehicles insured under the Policy unless a specific vehicle limitation is set by additional written endorsement executed by Insurer.

EXCLUDED DRIVERS SCHEDULE

Complete details for each excluded person. Add additional sheets if necessary.

3. EFFECT ON COVERAGE

3.1 While a person is designated an Excluded Driver, Insurer shall have no duty to defend or indemnify Insured, any other insured, or any person who claims coverage under the Policy for liability, medical expense, or property damage resulting from that Excluded Driver's operation of a motor vehicle.

3.2 Insurer's obligation to provide coverage for claims not involving the Excluded Driver remains subject to the terms, conditions, exclusions and limits of the Policy.

4. REPRESENTATIONS, ACKNOWLEDGMENTS, AND INDEMNITY

4.1 Insured represents and warrants that the information provided in this Form is true, complete and correct to the best of Insured's knowledge. Insured understands that Insurer will rely on these representations in recording the exclusion.

4.2 Insured acknowledges that excluding a driver may reduce or eliminate coverage available to Insured and other household members for claims involving that driver. Insured further acknowledges that the Excluded Driver may retain independent liability exposure for acts committed while operating a vehicle.

4.3 To the fullest extent permitted by law, Insured shall indemnify and hold harmless Insurer from any obligation or loss that arises from Insured's misrepresentation, omission, or failure to disclose material facts relating to the exclusion, including any claims asserted against Insurer by third parties arising out of such misrepresentation or omission.

I, the Insured, acknowledge that I have read and understood the exclusions, consequences, and representations set forth in this Form and that exclusion may affect my coverage and premiums.

5. NOTICES

5.1 All notices, requests, demands or other communications required or permitted under this Form shall be in writing and delivered to the addresses below by hand, certified mail (return receipt requested), or other delivery method providing proof of receipt.

6. MISCELLANEOUS

Governing Law: This Form shall be governed by and construed in accordance with the laws of the jurisdiction in which the Policy was issued, without regard to conflict of law principles.

Entire Agreement: This Form, together with the Policy and any endorsements expressly incorporated herein, constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior agreements and understandings, whether written or oral.

Severability: If any provision of this Form is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

Amendment and Waiver: No amendment, waiver, or modification of this Form shall be effective unless made in writing and signed by both Parties.

Counterparts: This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

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