Personal Service

Personal Service Insurance Company

Named Insured:______

Policy Number:______

Effective Date:______

NAMED DRIVER EXCLUSION ENDORSEMENT

It is agreed to amend the policy as follows: All coverage’s, including Liability, Medical Payments, Uninsured/Underinsured Motorist Bodily Injury, Uninsured Motorist Property Damage, and coverage for Damage to Your Covered Auto, are not afforded by this policy to anyone, including an “insured” or anyone acting on an “insured’s” behalf or at any “insured’s” request, while “Your Covered Auto”, or any auto other than “your Covered Auto” is being used, driven, or operated (with or without your permission) by the following persons.

Name of Excluded Driver:______DOB ______

Name of Excluded Driver:______DOB______

By signing this endorsement, I fully understand that coverage under this policy is excluded for me, any and all persons named above, or any other “insured” or potential “insured” who may have liability or responsibility for the actions or inactions of the person(s) named above, as otherwise applicable to the coverage under this policy. Additionally, by signing this endorsement, I fully understand and agree that coverage excluded under this endorsement for any person is not affected by whether or not a signed Uninsured/Underinsured Motorist rejection form is on file. I further agree that, in the event the Company shall become obligated to pay any sum or sums of money because of loss for which there would be no coverage because of the exclusion contained in this endorsement, I will reimburse the Company for any and all sums, costs and expenses incurred.

By signing the following, I agree to this endorsement of the policy.

______Signature of Named Insured Date

When a resident spouse is the excluded driver, Sign the following: I, being the excluded driver Under this policy, hereby consent and agree to The exclusion set forth above.

______Excluded Spouse’s Signature Date

Form PSU-806 (8/02)