Rental Vehicle Named Driver Exclusion Authorization

Rental Agreement Number
Renter's Name
Vehicle Information
Year / Make / Model
License Plate
Specifically Excluded Driver(s)
Acknowledgment
I acknowledge that the above-named person(s) is/are specifically excluded from operating the rental vehicle for the duration of the rental period. Should any excluded drivers operate the rental vehicle, all insurance coverage and protections may be void, and I may be solely liable for all damages or injuries resulting from any use by such excluded drivers.
Renter's Signature
Date
Rental Agent's Signature
Date