Insurance Development TRIA Form

INSURANCE DEVELOPMENT TRIA FORM

Insured / Applicant Information

Insured Name:

Date of Birth: Month Day Year

Policy Development Details

Insurer / Producer:

Purpose of Submission: New Policy Renewal Endorsement / Amendment

From Month Day Year   To Month Day Year

Coverage Types (Check all that apply)

Property Commercial General Liability Business Interruption Workers' Compensation Automobile Liability Inland Marine Other (describe below)

TRIA-Specific Information

Does the policy provide coverage for certified acts of terrorism subject to federal program allocation? Yes No

If coverage included, indicate insurer allocation method and limits:

Does the insured elect any optional TRIA-related endorsements or premium adjustments? Yes No

Risk Description & Exposures

Exclusions and Acknowledgements

The following are common exclusions or limitations that may apply to TRIA-related coverage. Acknowledgement is required.

War or warlike action by a sovereign or declared belligerent

Nuclear, biological, chemical weapon events where exclusion applies

Intentional acts by the insured or insured agents

Beneficiary / Payee Designation (if applicable)

Beneficiary 1 Name:

Relationship: Percentage:

Beneficiary 2 Name:

Relationship: Percentage:

Attachments Checklist

Please indicate attached documentation to support underwriting and TRIA determination:

ACORD application or equivalent

Loss runs (past 5 years)

Exposure summary / values

Other supporting documents (describe below)

Declaration, Representations and Certification

I, the undersigned, hereby declare and certify that the information provided in this Insurance Development TRIA Form is complete, true and accurate to the best of my knowledge. I acknowledge that this form is submitted for the purpose of underwriting, policy development and determining applicability of terrorism coverage and any federal program allocation related to certified acts of terrorism.

I understand and agree that the insurer may rely upon this information in determining coverage, premiums and the applicability of any endorsements or exclusions, and that any material misrepresentation or omission may result in denial of coverage, rescission or adjustment of benefits. I further acknowledge that premiums and limits associated with certified acts of terrorism may be subject to statutory assessments and recoupment procedures administered by relevant authorities and that the insurer may allocate losses in accordance with law and its internal procedures.

By signing below I authorize the insurer and its representatives to obtain, use and disclose underwriting information and to share information necessary to administer this policy and any applicable federal allocation, in accordance with applicable law. This authorization remains effective for the term of the policy and any endorsements issued in connection with it.

I attest under penalty of perjury that the foregoing is true and correct.

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