The Driver Exclusion Form serves as a risk management tool in U.S. auto insurance policies, allowing policyholders to explicitly exclude high-risk drivers from their coverage. This document is commonly used when a household member has a poor driving record, multiple violations, or presents an unusual insurance risk. The form must comply with state-specific insurance regulations and typically requires explicit acknowledgment from both the policyholder and the insurance company. Some states restrict or prohibit the use of driver exclusions, while others require specific language or additional documentation.
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1. Policy Information: Details of the insurance policy including policy number and effective dates
2. Policyholder Information: Name and contact information of the primary policyholder
3. Excluded Driver Information: Details of the driver being excluded from coverage
4. Exclusion Declaration: Clear statement of coverage exclusion and its implications
5. Acknowledgment: Policyholder's acknowledgment of understanding the exclusion
6. Signatures: Signature blocks for all required parties
1. Additional Vehicles: List of specific vehicles affected by the exclusion, used when multiple vehicles are covered
2. Temporary Exclusion Period: Specific timeframe for temporary exclusions, used when the exclusion is not permanent
3. State-Specific Disclosures: Additional required disclosures for specific states, included when required by state law
1. Vehicle Schedule: Detailed list of all vehicles covered under the policy
2. State-Required Forms: Additional forms required by specific state regulations
3. Premium Adjustment Schedule: Details of premium changes resulting from the exclusion
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