COAST NATIONAL INSURANCE COMPANY
DRIVER EXCLUSION ENDORSEMENT
Policy Number: __________________________
This endorsement, effective ________________ 12:01 a.m. Pacific Time forms a part of Coverage ID #. 5035817025 issued
to ___________________________ (Insureds Name) by Coast National Insurance Company.
This policy will not provide any insurance coverage when a vehicle is being operated or driven, with or without any insured’s
expressed or implied permission, by the following excluded driver. If we are required to make any payments under this policy
because of an accident which involves a vehicle that is being driven or operated by an excluded driver, you must repay us
those payments and any expenses. This endorsement applies to this policy and any continuation, renewal change or
reinstatement of this policy by the named insured, or the re-issuance of the policy by the Company.
Excluded Drivers Name(s): Excluded Drivers Date of Birth:
______________________________________________ ________________________
______________________________________________ ________________________
______________________________________________ ________________________
______________________________________________ ________________________
______________________________________________ ________________________
______________________________________________ ________________________
I agree that I will be charged a fully-earned Excluded Driver fee when there is an Excluded Driver listed on the policy. This
fee will only be charged once per policy term, regardless of the number of excluded drivers on the policy.
_____________________________________________________ ________________________
(
Signature of Named Insured) Date
By signing this Endorsement form, you agree to this change in your policy. All other terms and conditions of your policy
remain unchanged.
CN-CA-BO-502 (07/15)
