Insurance Quote TRIA Form

Insurance Quote TRIA Form

Applicant / Insured Information

Individual Corporation LLC Partnership Other

Policy Details

Policy Period: From to

Coverage Options

Please indicate which coverages are included in this quote:

Property Damage
Business Interruption
General Liability
Automobile Liability
Umbrella / Excess Liability
Workers' Compensation
Other:

TRIA Coverage Election

Under the Terrorism Risk Insurance Program (TRIA), certain certified acts of terrorism may be covered on a limited basis. The undersigned Applicant must make an affirmative election to include or decline TRIA-covered terrorism insurance as part of the policy quote. Select one option below. Selecting the inclusion will result in applicable TRIA surcharges and adjustments to premium.

I elect to include terrorism coverage subject to the terms, limitations and certification procedures of the applicable federal program and of the policy. I understand that coverage for certified acts of terrorism is limited by statute and policy terms, and that certain losses may not qualify as certified acts.

I decline terrorism coverage subject to the Terrorism Risk Insurance Program for the policy period shown above. I acknowledge that by declining I will not receive coverage for certified acts of terrorism under this policy.

Exclusions and Important Notices

The Applicant acknowledges that: (a) TRIA coverage is subject to federal certification of an act of terrorism; (b) coverage for certain events may be limited or excluded by policy language (including, where applicable, certain nuclear, biological, chemical or radiological losses); (c) TRIA establishes program deductibles, co-payments and other limitations that may affect recovery; and (d) actual coverage is determined by the policy terms and any final governmental determinations required by statute.

The Applicant further acknowledges that the insurer's offer of TRIA-covered terrorism insurance is conditioned upon the Applicant's representations herein and the insurer's underwriting review. Any misrepresentation or omission of material facts may render the coverage voidable in accordance with the policy and applicable law.

Beneficiary / Loss Payee

Complete if a beneficiary or loss payee is to be named for proceeds related to certified acts of terrorism.

Documentation Checklist

Provide copies of the following documents with this quote application where applicable:

Completed Application
Loss History for prior 5 years
Property Valuation / Schedule of Values
Description of Security / Risk Mitigation Measures
Other:

Declaration and Certification

The Applicant certifies that the information provided in this form is true, complete and correct to the best of the Applicant’s knowledge. The Applicant authorizes the insurer and its representatives to obtain and verify underwriting information and to charge any applicable premium, taxes, fees or surcharges for TRIA coverage if elected. The Applicant understands that inclusion of terrorism coverage is governed by statute, federal certification procedures and by the terms and conditions of the proposed policy, and that payment for applicable surcharges or adjustments is required as a condition of such coverage.

By signing below, the Applicant acknowledges the election above and agrees that this election shall apply for the policy period specified in this form unless otherwise amended in writing and agreed by the insurer.

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