Form_SCTNID_CTGRY.

MA11079330_SIGNFORM

973900084 $ 94549 INS EXCL POLWHITEFONT I3DSTILCWVP4UB2Q6ZANU4M6YF0005 RPUID TRACWHITEFONT BDF_AA

Policy Number: 973900084

Elchin Abdulov
Page 1 of 1

Operator Exclusion Form

It is agreed that the person named below will not operate any vehicle listed on the Coverage Selections Page, or any
replacement thereof, under any circumstances whatsoever.
Mariia Boloh
I am aware that under the terms of my Massachusetts Automobile Insurance Policy, if I, or someone on my behalf, provide
false, deceptive, misleading or incomplete information in any application or policy change request, and if such false,
deceptive, misleading or incomplete information increases the company’s risk of loss, the company may refuse to pay
claims under any or all of the Optional Insurance Parts of this policy. Such information includes the description and the
place of garaging of the vehicles to be insured, the names of all household members and customary operators required to
be listed and the answers given for all listed operators. Payments under Parts 3 and 4 may also be limited to those
amounts that the company is required to sell.
In addition, I am aware Massachusetts law requires that the company withhold payment of a Collision or Limited
Collision loss if the insured auto is being operated by a household member who is not listed as an operator on my policy.
Payment is withheld when the household member, if listed, would require the payment of additional premium on my
policy because the household member would be classified as an inexperienced operator or would require payment of
additional premium on my policy under the Merit Rating Plan.
This form must be signed by the named insured and excluded operator. You may fax the signed form to 1-877-280-5587
or mail it to:
Progressive
PO Box 31260
Tampa, FL 33631
I understand and agree that this Operator Exclusion Form shall apply to this policy and any renewal, reinstatement,
substitute, amended, altered, modified, or replacement policy with this company or any affiliated company, unless a
named insured revokes this election.

Signature of named insured Date

X ……………………………………………………………………………………………………………………………………………………….

Signature of excluded operator Date

X ……………………………………………………………………………………………………………………………………………………….

Form 9330 MA (11/07)

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