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Westan insurance po box 840 union city tn 38281 2025

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The document is a declination of insurance coverage from Westan Insurance Group, Inc., indicating that the named insured has chosen to decline the offered coverage after it was explained by the agent. It includes spaces for signatures and printed names of both the proposed insured and a witness.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the 'Named Insured' in the designated field. This should be the name of the individual or entity declining coverage.
Next, fill in the 'Coverage / Policy' section with details about the specific coverage being declined.
In the 'Insuring Company' field, specify the name of the insurance company offering the coverage.
Enter the 'Effective Date' for when this declination takes effect.
Indicate the date on which coverage was offered to the insured in the provided space.
Have the Proposed Insured sign in the designated area, confirming their decision to decline coverage.
The Witness must also sign and print their name in their respective fields to validate this document.
Finally, ensure that an Agent from Westan Insurance Group, Inc. signs and dates the form to complete it.

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Westan insurance po box 840 union city tn 38281 2025

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