Insurance Claim Signed TRIA

INSURANCE CLAIM — SIGNED TRIA

Claimant / Insured Name:

Policy Details

Insurer Name:

Type of Policy / Coverage Claimed

Select all coverages under which this claim is submitted:

Property (Building/Contents)

Business Interruption / Extra Expense

General Liability

Workers' Compensation

Commercial Auto

Cyber / Data Breach

Other (describe):

Claim Details

Date of Loss:    Time of Loss:

Documentation Checklist

Provide copies of applicable documents. Check items included with this submission:

Photographs / Video of Damage

Repair / Replacement Estimates

Proof of Ownership / Valuation

Contracts / Invoices

Payroll / Revenue Records (for BI)

Police, Fire or Other Official Report

Medical Records (if applicable)

Other supporting documents (describe):

TRIA-Related Information and Certification

Does this claim allege loss due to an act of terrorism as defined under the Terrorism Risk Insurance Act (TRIA)? Yes No

If yes, provide the basis for alleging that the loss is a terrorism-related loss, including known perpetrator information, alleged motive, and any official notices received:

Has any federal financial assistance, indemnity, or reinsurance been paid or committed for this same loss? Yes No

The claimant acknowledges that the insurer may disclose claim information to relevant authorities or to entities administering federal programs related to acts of terrorism, as permitted by law, for the purpose of determining coverage, coordinating benefits, or obtaining federal reinsurance.

Exclusions and Acknowledgements

By submitting this claim the claimant acknowledges that coverage is subject to all policy terms, conditions and exclusions. Typical exclusions may include but are not limited to: war or military action, nuclear hazard, intentional acts by the insured, wear and tear, pollution, and losses excluded by endorsement. The existence of such exclusions may affect coverage for terrorism-related losses.

I acknowledge receipt of the policy exclusions and understand that claim payment, if any, will be determined in accordance with the policy language, applicable law, and any federal program adjustments related to certified acts of terrorism.

Payee / Beneficiary / Claim Payment Instructions

Payee Name for Claim Proceeds:

Declarations and Certification

I declare that I am the claimant or an authorized representative of the claimant. I certify under penalty of law that the statements made in this claim form are true, accurate and complete to the best of my knowledge. I understand that knowingly providing materially false information or omitting material information may constitute insurance fraud and may subject me to civil and criminal penalties.

I authorize the insurer to investigate and obtain records reasonably necessary to evaluate this claim. I agree to cooperate with the insurer's investigation and to provide additional documentation upon request. I acknowledge that submission of this form does not by itself establish entitlement to payment under the policy and that the insurer retains the right to accept or deny the claim in accordance with policy terms.

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