Coverage Rejection and Declination Signed Acknowledgment Form

Documents when a client declines recommended coverage, limits, or endorsements and captures a signed acknowledgment for E&O risk management.

Client and Policy Details

• Client Name
• Agency Name
• Policy Number
  Optional if the account can be identified by client name and line of business.
• Line of Business
• Policy Effective Date
  Use only if needed to identify the coverage term involved.

Coverage Recommendation

• Recommendation Type
• Coverage, Limit, or Endorsement Recommended
• Reason for Recommendation
• Date of Coverage Discussion

Declination Details

• Client Decision
• Items Declined
• Client-Stated Reason for Declining
• Follow-Up Requested?

Client Acknowledgment and Consent

• Acknowledgment Statement
• Client Signature
• Date Signed
• Client Email
  Optional for sending a copy of the signed acknowledgment.

Agent Notes

• Agent Name
• Internal Notes