Insurance Excess Terrorism Selection

Insurance Excess Terrorism Selection

Insured Name:    Policy Number:    Insurer:

Applicant / Insured Information

Individual    Corporation    Partnership    Trust    Other

Policy Details

Policy Type:

Terrorism Excess Coverage Selection

The Applicant elects (select one):
Accept Excess Terrorism Coverage for the excess layer as set forth in this selection and the applicable excess endorsement.
Decline Excess Terrorism Coverage for the excess layer (no additional premium required; applicable terrorism exclusions shall apply).

If accepting, select coverage basis (select one):
Full Terrorism Coverage, including acts otherwise classified as certified acts of terrorism where permitted by law
Non-certified Terrorism Coverage only (excludes certified acts where separate program applies)
Limited Coverage — structural damage only, business interruption excluded

Aggregate Sublimit for Certified Acts (if any):    Retroactive Date (if applicable):

Exclusions and Limitations (Acknowledgement Required)

The Applicant acknowledges that, subject to acceptance of this selection by the Insurer, coverage is subject to the applicable policy terms, conditions and endorsements. The Applicant specifically acknowledges the applicability of the following standard exclusions and limitations unless expressly modified in writing by endorsement:

Loss, damage or liability arising out of or contributed to by nuclear incident or radioactive contamination.
Loss caused by war, warlike action, hostilities (whether declared or not), invasion, insurrection, rebellion, revolution, or military action.
Loss caused by pollution, contamination or biological agents unless specifically included by endorsement.
Loss arising from intentional acts or those expected or intended by the insured or beneficiaries.
Definitions, thresholds and certification procedures applicable to acts of terrorism as set forth in the policy and endorsement.

Declaration and Certification

By signing below the Applicant certifies that the information provided on this Insurance Excess Terrorism Selection is true and complete to the best of the Applicant's knowledge. The Applicant authorizes the Insurer to attach the appropriate excess terrorism endorsement to the policy when the Insurer accepts this selection and to charge the premium as indicated. Acceptance of this selection by the Insurer is required to create coverage; until so accepted, no coverage change is effective.

The Applicant understands that premium adjustments, audits, and retrospective rating provisions of the policy remain applicable. The Applicant further acknowledges that this selection may be subject to regulatory approval and that any coverage provided will be subject to the full terms and conditions of the policy and any applicable endorsements, including those that exclude or limit coverage for certain acts of terrorism.

I certify under penalty of perjury that the information provided is accurate and that I have authority to make this selection on behalf of the Named Insured.

Beneficiary Information (For return premium or proceeds, if applicable)

Provide up to three beneficiaries. Percentages must total 100% if more than one beneficiary is listed.

Attachments and Supporting Documentation

Please attach or list documentation submitted in support of this selection (e.g., updated underlying policy declarations, loss runs, engineering reports).

Underlying Policy Declarations
Loss Runs (most recent 5 years)
Engineering / Inspection Reports
Prior Applications and Endorsements

Signature

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