Business Owner's Policy Terrorism Form

Business Owner's Policy Terrorism Form

Insurer Name:    Policy Number:

Producer / Agent:    Agency Code:

Applicant / Insured Information

Date of Birth / Organization Date:    Contact Phone:    Email:

Policy Details

Policy Period Start:    End:

Terrorism Coverage Election

The Insured selects one of the following options regarding coverage for loss arising out of an act of terrorism. Check exactly one box and complete associated fields where indicated.

 Accept terrorism coverage as an endorsement to the policy. Coverage shall be subject to the terms, limits, conditions and exclusions of the policy and the terrorism endorsement.

 Decline terrorism coverage. By declining, the Insured acknowledges that no coverage will apply for losses arising out of an act of terrorism as defined below.

Definitions

"Act of Terrorism" means an act, including but not limited to the use of force or violence or the threat thereof, by any person or group of persons acting alone or on behalf of or in connection with any organization, committed for political, religious, ideological or similar purposes, including the intention to influence any government or to put the public or a section of the public in fear. Coverage for an act of terrorism is limited to losses that are the direct physical loss or damage resulting from such an act, subject to the terms and limitations of the policy and endorsement.

"Certified Act" means an act of terrorism certified as such pursuant to applicable statutory procedures under which specified limitations or sublimits may apply to recovery. The application of any certification process, certification date or other procedural mechanism shall be governed by the terms of the policy, endorsement and applicable law.

Exclusions

Unless otherwise expressly endorsed, this endorsement excludes coverage for loss or damage directly or indirectly caused by or resulting from: (a) war, invasion, act of foreign enemy, hostilities (whether war declared or not), civil war, rebellion, revolution, insurrection or military usurpation; (b) nuclear reaction, radiation, or radioactive contamination; (c) willful acts, fraudulent acts, or criminal acts by the insured; (d) loss resulting from the release, dispersal, or escape of chemical, biological, radiological or similar agents; (e) loss of electronic data not resulting in direct physical loss of covered property; and (f) any consequential or indirect loss not specifically covered by the policy.

The Insured expressly acknowledges that certain exclusions may limit recovery for particular types of terrorism-related loss even where terrorism coverage is elected.

 Insured acknowledges receipt and review of the exclusions set forth above.

Claims Reporting (for terrorism-related loss)

Documentation Checklist (attach as available):

  Police report

  Photographs of damage

  Repair/repair estimates

  Completed proof of loss

Beneficiary Designation (for policy proceeds, if applicable)

Premium, Payment and Allocation Terms

Premium for terrorism coverage, if elected, shall be payable in accordance with the policy premium terms. The Insured agrees that any premium allocation between terrorism coverage and other coverages shown above is the agreed allocation for purposes of premium calculation and any applicable limits of liability.

Cancellation and Nonrenewal

Coverage for terrorism may be subject to specific cancellation or nonrenewal provisions. The insurer may cancel or nonrenew the terrorism coverage consistent with the policy terms and applicable law for reasons including but not limited to nonpayment of premium, material misrepresentation, or changes in risk profile. The Insured will be provided the notice required by the policy and applicable law prior to cancellation or nonrenewal of terrorism coverage.

 Insured acknowledges the cancellation and nonrenewal provisions stated above.

Declaration and Certification

By signing below, the Insured declares that the information provided in this form is true and complete to the best of the Insured's knowledge and belief. The Insured understands and agrees that acceptance of terrorism coverage is subject to the terms, conditions, limitations and exclusions of the policy and any terrorism endorsement. The Insured authorizes the insurer and its authorized representatives to obtain and verify information relevant to underwriting and claims, including inspection of premises. The Insured acknowledges that any material misrepresentation may void coverage for terrorism losses to the extent permitted by law.

The Insured further certifies that they have read and understand the definitions, exclusions and conditions set forth in this form and any attached endorsements, and that they have chosen the election indicated above with knowledge of the consequences of such election.

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