515A. EXCLUSION OF NAMED DRIVER AND PARTIAL REJECTION OF COVERAGES
This endorsement forms a part of Policy No. issued to
by the at its agency
located at and is effective from (12:01 A.M. Standard Time)
(The Information above is required only when this endorsement is issued subsequent to preparation of the policy)
This endorsement forms a part of the policy to which attached, effective from its date of issue unless otherwise stated herein.
WARNING
READ THIS ENDORSEMENT CAREFULLY!
This acknowledgement and rejection is applicable to all renewals issued by us or any affiliated insurer.
However, we must provide a notice with each renewal as follows: “This policy contains a named driver exclusion.”
You agree that none of the insurance coverages afforded by this policy shall apply while
**NAME **DOB **RELATIONSHIP TO INSURED
is operating your covered auto or any other motor vehicle.
You further agree that this endorsement will also serve as a rejection of Uninsured/Underinsured Motorists Coverage and
Personal Injury Protection Coverage while your covered auto or any other motor vehicle is operated by the excluded driver.
Acknowledged by
(Your signature)
FORM 515A – EXCLUSION OF NAMED DRIVER AND PARTIAL REJECTION OF COVERAGES
Texas Standard Automobile Endorsement
Prescribed March 18, 1992
**PLEASE FILL IN ANY MISSING INFORMATION
