Form_SCTNID_CTGRY.

XX1106FAXCRC_OTHER

Progressive
PO Box 31260
Tampa, FL 33631
Policy Number: 955355504
Underwritten by:
Progressive Direct Insurance Co
Policyholder:
Pedro dario Estrella gonzalez
June 13, 2022
Page 1 of 1

Customer Service
1-800-776-4737
24 hours a day, 7 days a week
1-877-280-5587 (fax)

Mailing Address:
Progressive
PO Box 31260
Tampa, FL 33631-3260

Requested policy documents

………………………………………………………………………………………………………………………………………………………..

Excluded Drivers Form

Please sign and return the attached form and include this page for reference. You may fax or mail the
information to Progressive. Thank you.
Form_SCTNID_CTGRY.RI05119330_SIGNFORM

<docindex><index>EXCL</index></docindex>

Policy Number: 955355504

Pedro dario Estrella gonzalez
Page 1 of 1

Named Driver Exclusion Election

You have named the following persons as excluded drivers under this policy:

Date of Birth:
Date of Birth:
Date of Birth:
Date of Birth:
No coverage is provided for any claim arising from an accident or loss involving a motorized vehicle being operated by an
excluded driver. This includes any claim for damages made against any named insured, resident relative, or any other
person or organization that is vicariously liable for an accident or loss arising out of the operation of a motorized vehicle by
the excluded driver. However, if any named insured or a resident relative gives permission to an excluded driver to operate
a motor vehicle owned or leased by any named insured or a resident relative and covered under this policy, this exclusion
shall not apply to any vicarious liability imposed by law on any named insured or a resident relative, up to the minimum
limits required by the Rhode Island Motor Vehicle Safety Responsibility Act, for a claim for damages caused by an accident
or loss arising out of the operation of such motor vehicle by the excluded driver.
This form must be signed by the named insured. You may fax the signed form to 1-877-280-5587 or mail it to:
Progressive
PO Box 31260
Tampa, FL 33631
I understand and agree that this Named Driver Exclusion election shall apply to this policy and any renewal, reinstatement,
substitute, amended, altered, modified, or replacement policy with this company or any affiliated company, unless a
named insured revokes this election.

Signature of Named Insured Date

X ………………………………………………………………………………………………………………………………………………………………

Form 9330 RI (05/11)