Teen Driver Exclusion Agreement

Policyholder Information

Name Address Policy Number

Excluded Driver Information

Excluded Driver Name Relationship to Policyholder Date of Birth Driver's License Number

Agreement

I, the undersigned policyholder, hereby request and agree to exclude the person named above from all coverage while operating any vehicle under the referenced policy. I understand that any claim caused by or involving the excluded driver will not be covered under this insurance policy. I acknowledge and accept full responsibility for any consequences resulting from this exclusion.