Insurance Property TRIA Form

INSURANCE PROPERTY TRIA FORM

This form documents a property loss claim for which the insured requests consideration under the federal terrorism risk insurance program (TRIA). Completion of this form does not by itself establish entitlement to coverage. The insured must provide truthful, complete information and cooperate with the insurer's investigation and any governmental review associated with certification of an act of terrorism.

APPLICANT / INSURED INFORMATION

Individual Corporation LLC Other:

Date of Birth (if individual): Day: Month: Year:

POLICY DETAILS

Policy Period Start: End:

Building Contents Business Interruption Extra Expense Other:

PROPERTY / LOCATION DETAILS

LOSS / EVENT DETAILS

Date of Loss: Month: Day: Year:

Suspected Terrorism Explosion Fire Vandalism Other:

DOCUMENTATION CHECKLIST

Please indicate documents submitted or to follow:

Police report Fire department report Photographs Repair estimates

Inventory lists Proof of ownership Contracts / leases Other:

PAYEE / BENEFICIARY INFORMATION

Relationship to Insured: Percentage of Proceeds:

EXCLUSIONS, LIMITATIONS, AND ACKNOWLEDGEMENTS

The policy may contain exclusions, limitations, or special provisions applicable to losses caused by certain categories of wrongdoing or hostile acts. Typical exclusions include acts of war, nuclear incidents, and intentional loss by the insured. TRIA provides for federal participation only where a violent act meets statutory criteria and is certified for program coverage; federal participation is subject to statutory limitations and may not cover all amounts otherwise payable under the policy.

By checking the box below, the insured acknowledges having read and understands that federal participation, if any, is limited to certified acts of terrorism under the federal program and that the insurer may seek federal reimbursement for amounts paid on account of a certified act.

I acknowledge and understand the exclusions, limitations, and potential federal participation limits described above.

CERTIFICATION AND AUTHORIZATION

I certify to the best of my knowledge and belief that the information provided in this form and any attachments is true, complete and correct. I further certify that I reasonably believe the loss described herein was caused by an act that may be eligible for consideration under the federal terrorism risk insurance program. I authorize the insurer to disclose information concerning this loss to investigators, law enforcement, reinsurers and the federal program administrator as necessary for the processing and potential certification of this loss. I understand that knowingly making a false statement or concealing material information may result in denial of coverage and may subject me to civil or criminal penalties under applicable law.

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