Coverage Rejection and Declination Signed Acknowledgment Form

Documents when a client declines recommended coverage options or chooses lower limits, with a signed acknowledgment to reduce E&O exposure.

Client and Policy Information

• Client / Business Name
• Policy Number
• Policy Effective Date
• Agency Contact / Producer

Coverage Recommendation

• Recommended Coverage Type
• If Other, describe the recommended coverage
• Recommended Limit / Amount
  Enter the recommended limit or amount in a clear format, such as $1,000,000 or 100/300/100.
• Reason the coverage or limit was recommended

Declination Details

• What is the client declining?
• Describe the declined coverage, limit, or endorsement
• Client-selected alternative, if any
  Examples: lower limit, narrower endorsement, or no coverage change.
• Client's reason for declining

Risk Disclosure and Acknowledgment

• Risks explained to client
• If Other, describe the risk explained
• Client acknowledgment
• Consent to record this declination
  This records your declination in the agency file for documentation and audit trail purposes.

Signature and Submission

• Client Signature
• Date Signed
• Printed Name
• Additional Notes