Waiver of Coverage Form

Important:
  1. After completing and submitting this form you will need to send us a copy of your E&O policy's Declaration page.
  2. If your E&O coverage is issued through a policy for an agency with which you are affiliated, you will also need to send us a copy of the policy endorsement which names you as an individual insured under the agency's coverage.
  3. Send all appropriate forms to:
    Mail:
    Affinity Insurance Services, Inc.
    159 East County Line Road
    Hatboro, PA 19040

    Fax:
    877.443.9183
After you submit this form, a copy of your completed form will be available to print and retain for your records.

I elect to maintain outside coverage and not participate in the sponsored Errors and Omissions program.

* Required
 
General Information
* Company ID
  (Found on the Waiver of Coverage Form mailed to you.)
* Agent ID
* First Name
  Middle Initial
* Last Name
* Address
* City
* State
* Zip -
* Is this a change of address?
* Phone Number () -
* Email Address
 
Current E&O Insurance Information
* Current E&O Insurer
* Current E&O Expiration Date on File / /
* Limits of Liability /
  (Per Claim Limit / Aggregate Limit)
 
By electronically submitting this form I hereby elect to waive coverage under the sponsored Errors and Omissions program, and acknowledge that I currently maintain Errors & Omissions insurance through another insurer. The information I am providing is true and valid, to the best of my knowledge. I also understand that in order to waive coverage I am required to send, by mail or fax, all necessary documents listed on this form.