Insurance LLC TRIA Form

INSURANCE LLC TRIA FORM

Applicant / Insured Information

Entity Type: LLC Corporation Partnership Other:

Contact Person:   Phone:   Email:

Policy Details

Policy Number:   Policy Type: Property General Liability Commercial Auto Workers' Compensation Other

Policy Period: From to

TRIA Coverage Election

The undersigned insured acknowledges the availability of terrorism coverage under the policy identified above and makes the following election for the policy period specified. Selection is binding for the full policy period unless otherwise agreed in writing by the insurer and insured.

Elect to purchase Terrorism Coverage (subject to underwriting and premium adjustment). If electing, specify TRIA Coverage Sublimit: Additional Premium for TRIA coverage:

Decline Terrorism Coverage (insured understands terrorism losses will not be covered under this policy for the policy period).

Coverage Options & Limitations

Select coverage elements to apply where applicable. Insurer may apply endorsements to limit or expand the scope of coverage for certified acts of terrorism.

Coverage for certified acts of terrorism (as defined in insurer endorsement).

Exclude nuclear, radiological, biological, or chemical events unless expressly endorsed.

Exclude war or acts of foreign hostility.

Exclusions and Special Conditions

Insurer and insured acknowledge that terrorism coverage is subject to specific exclusions, monetary sublimits, and shared or statutory deductibles. The insured agrees that any exclusion or limitation expressly set forth in the policy or endorsement shall apply to losses arising from acts of terrorism, except to the extent expressly provided otherwise in a written endorsement signed by the insurer.

Beneficiary Information

Designate beneficiary(ies) for any policy proceeds payable to the insured's estate or named payee in the event of loss where permitted by policy terms. Percentages must total 100% where applicable.

Relationship:   Share %:

Relationship:   Share %:

Claims Notification and Documentation

In the event of a loss for which TRIA coverage may apply, notify the insurer promptly and provide full documentation. Failure to timely notify or provide required documentation may prejudice coverage.

Documentation Checklist:
Police / incident report where applicable
Photographs of damage
Repair estimates and supplier invoices
Business financial records showing loss of income (if applicable)

Declarations and Certification

By signing below, the insured certifies that the information provided in this form is true and complete to the best of the insured's knowledge and belief. The insured understands that any willful misrepresentation of a material fact may result in denial of coverage or rescission of the endorsement.

The insured further acknowledges that:
1. Election to purchase terrorism coverage, if made above, shall be subject to premium adjustment, underwriting approval, and any applicable statutory or policy provisions limiting insurer liability.
2. Coverage for an act of terrorism may be limited by monetary sublimits, exclusions for certain agents or means (including nuclear, biological, chemical, or radiological agents), and by statutory shared deductibles or co-payments where applicable.
3. The insurer may require additional documentation or endorsements to implement the election set forth in this form.

The insured authorizes the insurer to rely on this form as binding election or declination for the policy period stated and acknowledges that any change to this election requires written agreement between insurer and insured. The insured agrees to cooperate fully in underwriting reviews and claims investigations, and to authorize release of information necessary to evaluate the election and any claim.

Fraud Warning: Any person who knowingly presents false information in connection with an insurance transaction may be subject to civil or criminal penalties under applicable law.

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