NAMED DRIVER EXCLUSION ENDORSEMENT …

1 NAMED DRIVER EXCLUSION ENDORSEMENTE ffective: xxxxxxxNothing herein contained shall be held to alter, vary, waive, or extend any of the terms, conditions, agreements, or limits ofthe under mentioned policy other than as stated herein COVERAGE IS PROVIDED FOR ANY CLAIM ARISING FROM AN ACCIDENT OR LOSS INVOLVING A VEHICLEBEING OPERATED BY AN EXCLUDED PERSON. THIS INCLUDES ANY CLAIM FOR DAMAGES MADE AGAINST ANYNAMED INSURED, RESIDENT RELATIVE, OR ANY OTHER PERSON OR ORGANIZATION THAT IS VICARIOUSLYLIABLE FOR AN ACCIDENT OR LOSS ARISING OUT OF THE OPERATION OF A VEHICLE BY THE EXCLUDEDPERSON. I ALSO AGREE THAT COVERAGE IS EXCLUDED FOR ANY NEGLIGENCE WHICH MAY BE IMPUTED ONME BY LAW ARISING OUT OF THE MAINTENANCE, USE OR OPERATION OF A MOTOR VEHICLE BY ANYEXCLUDED PERSON. I UNDERSTAND AND AGREE THAT THIS NAMED DRIVER EXCLUSION ELECTION SHALL APPLY TO THIS POLICYAND ANY RENEWAL, REINSTATEMENT, SUBSTITUTE, AMENDED, ALTERED, MODIFIED OR REPLACEMENTPOLICY WITH THIS COMPANY UNLESS A NAMED INSURED REVOKES THIS ELECTION IN WRITING AND WEAGREE TO REMOVE THE consideration of the premium for which the policy is written, it is agreed that the company shall not be liable and noliability or obligation of any kind shall be attached to the company for losses or damages sustained after the effective date ofthis ENDORSEMENT while any motor vehicle insured herein under is driven or operated by:Excluded DRIVER :Date of Birth:Excluded DRIVER :Date of Birth:Excluded DRIVER :Date of Birth:Excluded DRIVER :Date of Birth:Excluded DRIVER :Date of Birth.

2 By signing this form, I acknowledge my selection of the NAMED DRIVER EXCLUSION ENDORSEMENT and agree to this change in mypolicy. I acknowledge and understand this ENDORSEMENT becomes part of my personal auto policy at its effective date and s Signature:Date:Applicant s Signature:Date:AGENCY NAME AND ADDRESSPOLICY PERIODNAMED INSURED AND ADDRESSAGENCYToCOMPANYPOLICY NUMBERFrom