Family Member Named Driver Exclusion Form
Policyholder Name
Policy Number
Insurance Company
Effective Date
Excluded Family Member Information
Full Name
Relationship to Policyholder
Date of Birth
Driver’s License Number
State of License
Exclusion Acknowledgement
Please read and acknowledge:
I understand and agree that the individual named above is excluded from coverage under my automobile insurance policy for any and all vehicles insured under this policy. I acknowledge that any liability, loss, or damage caused while the excluded driver is operating a covered vehicle will not be covered, and I accept full responsibility.
Policyholder Signature
Date
Agent/Representative Signature
Date
This form must be completed, signed, and returned to your insurance company to process the named driver exclusion.