Voiding Automobile Insurance While a Named Person is operating a Covered Automobile
This Endorsement forms a part of Policy Number: _____________________________________________

Issued to: _______________________________________________________________________________

By the Company at its Agency located at: ____________________________________________________
The premium for this policy and our continuing this policy in force is based on your telling us that the person named below will not operate or use a covered auto. Therefore, this policy is changed by adding the following exclusion:
  This insurance does not apply to damages, accidents, or losses caused while a covered auto is being operated or used by _____________________________________ whether or not you have given your express or implied permission for this operation or use.  
All other terms of this policy remain unchanged.
This endorsement takes effect at 12:01 a.m. Standard Time on the date indicated below.
The Named Insured (or Authorized Representative) accepts this endorsement as witnessed by his/her signature signifying agreement.
_____________________________________________________________      ____________________________________
     Excluded Operator's Signature          Date
_____________________________________________________________      ____________________________________
     Named Insured / Authorized Signature          Effective Date of Endorsement
_____________________________________________________________      ____________________________________
     Signature of Agent          Date
MK2003 (10/97)