Insurance Terrorism Application

INSURANCE TERRORISM APPLICATION

Applicant / Insured Information

Policy Details

Policy Type: Property Business Interruption General Liability Other

Policy Period: From to    Retroactive Date (if applicable):

Coverage Selections and Endorsements

Select desired terrorism coverage options (check all that apply):

Certified Acts coverage (per applicable statute)
Non‑certified Acts coverage (sublimit may apply)
Aggregate sublimit elected — specify amount:
Business Interruption / Time Element coverage
Employee Injury Exclusion applies

Exclusions and Limitations

The following exclusions are standard to terrorism coverage and apply unless expressly endorsed: war or warlike action; nuclear, biological, chemical, or radiological release; governmental seizure or destruction; punitive damages not insured by endorsement. By signing this application the Applicant acknowledges receipt and understanding of these typical limitations.

Applicant affirms that any request for modification of standard exclusions must be submitted in writing and is subject to underwriter approval and possible premium adjustment.

Beneficiary / Loss Payee

Loss Payee / Beneficiary Name:

Prior Loss Experience (Last 5 Years)

Complete all known material losses related to terrorism or political violence for the period requested. Attach loss runs where available.

Supporting Documentation Checklist

Please attach copies where indicated and initial acknowledgment where required.

Schedule of locations and values
Loss runs (last 5 years)
Prior insurance declarations
Engineering / vulnerability report (if available)
Appraisal or valuation documentation

Declarations, Representations and Authorizations

The Applicant represents and warrants that the information contained in this application and any attachments is true and complete to the best of the Applicant's knowledge. Material misrepresentation, omission or fraudulent statement may render any resulting policy void or permit the insurer to rescind coverage or deny claims in accordance with policy terms and applicable law.

Applicant authorizes the insurer, its representatives, and authorized agents to obtain and verify information, including but not limited to prior insurance and loss history, financial records, and loss control inspections. The Applicant further agrees that the insurer may disclose information as required by law or as necessary to underwrite the risk, adjust claims or as authorized by the Applicant.

Coverage granted under any terrorism endorsement is subject to the terms, conditions, limitations and exclusions of the endorsement and the underlying policy. Premium, limits, and applicable sublimits will be determined by the insurer based upon underwriting review. Nothing in this application binds the insurer to issue or renew coverage until a formal policy has been issued and premiums paid as required.

Certification

By signing below, the Applicant certifies that the statements set forth in this application are accurate and complete. Applicant understands that issuance of terrorism coverage may be conditioned upon further investigation, payment of additional premium, and acceptance of any required endorsements. Applicant acknowledges receipt of a copy of this application.

Sign Now