DESIGNATED DRIVER EXCLUSION - Western General

1 All household members 14 years old and older must be listed as a DRIVER or excluded from this policy. We shall not be liable to any person forany damages, losses or claims arising out of the excluded DRIVER s operation or use of an Insured Motor Vehicle, whether or not suchoperation or use was with the express or implied permission of a person under this policy. We shall also not be liable for any negligencewhich may be imputed by law to the Named Insured arising out of the maintenance, operation or use of a motor vehicle by the excludedperson. This EXCLUSION shall not apply to Uninsured Motorists or Underinsured Motorists coverage. This EXCLUSION shall continue to bebinding with respect to any continuation or renewal of the ) Full Name:_____ Gender_____ _____ Rel.

2 To Applicant:_____2) Full Name:_____ Gender_____ _____ Rel. to Applicant:_____3) Full Name:_____ Gender_____ _____ Rel. to Applicant:_____4) Full Name:_____ Gender_____ _____ Rel. to Applicant:_____WARNING: BY SIGNING HERE, YOU ARE AGREEING THAT THERE WILL BE NO INSURANCE COVERAGE EXCEPT FORUNINSURED MOTORISTS COVERAGE AND UNDERINSURED MOTORISTS COVERAGE WHEN THE VEHICLE(S) IS BEINGDRIVEN BY THE PERSON(S) LISTED ABOVE. DO NOT SIGN THIS EXCLUSION UNLESS YOU READ AND UNDERSTAND NUMBER:DDE TX (02/11) Western General INSURANCE SERVICES5230 Las Virgenes Road, Calabasas, CA 91302 DESIGNATED DRIVER EXCLUSIONXA pplicant Signature (Named Insured)Date