Policy Numba: 611M799

VeaieaA *ms*
Page'! d 1

Named Driver Exclusion Election

named the following persons as drivers under fris policy:

ro Date of Bir

Date of Birth:

Date of Birth:

Date oi Birti'r:

No coverage is provided for any daim arising from an accident or loss involving a motorized vehide being operated or
used by an exduded driver. This includes any daim for damages made against any named insured, resident relative, or
any other person or organization that is yicariously liable fu an accident or loss arising ow of the operation or use of a
motorized vehide by the excluded driver.

The California lnsurance Code requires an insurer to provide uninsured motorist coverage in each bodily injury liability
insurance policy it issues covering liability arising out of the ownership, maintenance, or use of a motor vehicle. those
provisions also permit the insurer and the applicant to delete the coverage completely or to delete the coverage when a
motor vehicle is operated by a natural person or persons designated by name. Uninsured motorist qrverage insures the
insured, his CI her heirs, or legral represmtatiyes for all stnm wiftir tre limi6 establisM by law, that ttre pason or
persons are legally entitled to recover as damages for bodily injury, induding any resulting sickness, diseasg or death. to
the insured from the owner or operator of an uninsured motor vehicle not owned or operated by the insured or a resident
of tre same household. An uninsured motor vehide indudes an underinsured motor vehide as defined in subdivision (p)
'l
of Section 1 580.2 of the lnsurance Code.

lhis lorm must be siisned by tT:a#s:i[sff:; lax the $sned lorm to r'877-280-5s87 or mail it to:

#J;.,
P0 8ox31260 t
Tampa, tL 33631

I understand and agree that this Named Driver Exdusion election shall apply to fris policy and any renewal, reinstatement,
substitute, amended, altered, modified, or replacement policy wittr this company or any affiliated company, unless a
named insured revokes this election.

Date

X
Fsm 9330 CA (J 1108)