Legal Insurance Waiver

LEGAL INSURANCE WAIVER

This Legal Insurance Waiver (the "Waiver") is made effective as of , by and between Client Name: and Provider Name: .

Recitals

WHEREAS, Provider offers access to legal insurance or legal services coverage to eligible individuals, and Provider may subsidize or administer such coverage under an agreement or plan identified as Plan Identifier: ; and

WHEREAS, Client has been offered enrollment or participation in the legal insurance coverage and has been informed of the material terms, costs, and scope of covered legal services; and

WHEREAS, Client elects to decline or waive participation in the legal insurance coverage and acknowledges certain rights and responsibilities as set forth below.

NOW, THEREFORE

In consideration of the mutual promises set forth herein and 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 Waiver, the following terms shall have the meanings set forth below: "Coverage" means the legal insurance benefits and services described in the plan identified above; "Claim" means any demand, suit, action or proceeding arising out of facts or circumstances for which Coverage might otherwise apply; and "Effective Date" means the date set forth above.

2. Acknowledgment and Election to Waive

Client acknowledges that Provider offered Coverage and provided sufficient information regarding the nature and scope of Coverage, including any applicable premiums, co-payments, limitations, and exclusions. Client hereby elects to decline Coverage and knowingly and voluntarily waives enrollment in the Coverage effective as of the Effective Date. Client confirms the selection below:

I decline enrollment in the legal insurance Coverage and understand that I will not receive benefits under the plan.

3. Scope of Waiver and Release

Client expressly waives any right to assert a Claim against Provider for denial of Coverage or failure to enroll for the period for which this Waiver applies, provided that this Waiver shall not release claims arising from Provider's gross negligence, willful misconduct, or intentional misrepresentation regarding material terms of the Coverage that occur prior to execution of this Waiver. This Waiver does not limit Client's rights under applicable statutory protections except as expressly set forth herein.

4. Representations and Warranties

Client represents and warrants that Client (a) has been provided a reasonable opportunity to review the terms of Coverage prior to executing this Waiver, (b) is competent to make this election, and (c) is not relying on any oral or written representations other than the written terms of this Waiver and the disclosed plan documents. Provider represents that it has provided material terms of the Coverage as required by its policies and applicable law.

5. Indemnification

To the fullest extent permitted by law, Client shall indemnify, defend and hold harmless Provider and its officers, directors, employees and agents from and against any liabilities, losses, damages, claims, costs and expenses (including reasonable attorneys' fees) arising from Client's decision to decline Coverage, except to the extent such liabilities result from Provider's gross negligence or willful misconduct.

6. Confidentiality

The parties agree to keep confidential the terms of this Waiver and any non-public information exchanged in connection with the decision to waive Coverage, except as required by law, regulation, or valid court order. Notwithstanding the foregoing, Provider may disclose the existence of this Waiver to plan administrators, auditors, or regulators as necessary.

7. Notices

All notices hereunder shall be in writing and delivered by hand, nationally recognized overnight courier, or certified mail, return receipt requested, to the addresses set forth below or such other address as a party designates in writing. Notices shall be effective upon receipt.

8. Amendment; Waiver; Counterparts

This Waiver may be amended only by a written instrument executed by both parties. No failure or delay by either party in exercising any right shall operate as a waiver of that right, nor shall any single or partial exercise preclude other or further exercise of that right. This Waiver may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

9. Governing Law; Venue

This Waiver shall be governed by and construed in accordance with the laws of the state specified below without regard to conflict of law principles. The parties consent to the exclusive jurisdiction and venue of the courts located in the county specified below for any dispute arising out of or relating to this Waiver.

10. Entire Agreement; Severability

This Waiver constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, proposals and communications, whether written or oral. If any provision of this Waiver is held to be invalid, illegal or unenforceable by a court of competent jurisdiction, such provision shall be deemed modified to the minimum extent necessary to make it valid and enforceable, and the remaining provisions shall remain in full force and effect.

11. Additional Acknowledgments

Client certifies that Client has read and understands this Waiver, has had the opportunity to ask questions, and executes this Waiver voluntarily. If Client is executing on behalf of another person or entity, Client represents that Client has the authority to execute binding agreements on behalf of such person or entity and will attach evidence of such authority if requested by Provider.

Execution

The parties have caused this Waiver to be executed by their duly authorized representatives as of the dates set forth opposite their signatures below.

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