Policy Renewal
Named Driver Exclusion Addendum

Policy Number:
Policyholder Name:
Effective Date:
Excluded Driver(s):
Name Date of Birth Relationship
Addendum Details:

The named driver(s) listed above are specifically excluded from coverage under this policy. There is no coverage for claims arising from accidents or losses that occur while any excluded driver is operating a vehicle insured under this policy.

Acknowledgment:

The Policyholder acknowledges and agrees to the exclusions above, and understands that no coverage will apply while any of the excluded driver(s) operate any vehicle covered by this policy.

Policyholder Signature:
Date:
Agent/Representative:
Date: