Commercial Insurance Declination Form
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1COMMERCIAL INSURANCE DECLINATION FORM
Named Insured: ____________________________________________________________
Coverages Offered
Declined
General Liability
Liquor Liability
Cyber Liability
Workers Compensation
Directors & Officers Liability
Professional Liability (errors & omissions)
Business Auto (All coverages)
Business Auto (vehicle physical damage)
Umbrella / Excess
Inland Marine - Contractor’s tools & equipment
Inland Marine – Jewelers block
Inland Marine – Builders Risk
Property – Building
Property – Business Personal Property
Property – Business Income
Property – Ordinance / Law Coverages
Property – Equipment breakdown
Flood
Crime (Employee Dishonesty)
Accident insurance for students or volunteers
Signature of insured: _____________________________________________
Date: _______________
(Insured signature must be owner or executive officer)
Signature of Agent: _______________________________________________
Date________________
Policy Effective dates: ____________________ Policy Expiration dates_____________________________
This signed document is part of the client file for the policy term indicated.
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Parent category: Medical