What is the primary purpose of this form?

The form consolidates terrorism-related costs into an itemized record for insurer review, reinsurance reporting, and potential government program eligibility; it organizes invoices, estimates, and certifications to support coverage determinations.

Can this form be signed electronically?

Yes. Electronic signatures that meet ESIGN and UETA criteria are acceptable when the platform captures intent, signer attribution, consent, and retains a reproducible record of the signed document and audit trail.

Who must sign the form on the insured side?

An authorized representative with authority to bind the insured—typically a risk manager, officer, or designated claims contact—must sign and date; the signer certifies accuracy of the cost estimates and attached supporting documentation.

What supporting documents should be attached?

Attach vendor invoices, contractor estimates, photographs, inspection reports, permits, payment receipts, and any forensic or security reports that substantiate damage, remediation, and the terrorism cause.

How long should I keep submitted records?

Retain the form and supporting records for the claim lifecycle plus a multi-year period: at minimum three years from filing for tax purposes and six years for HIPAA-regulated health documents where applicable.

What if the insurer disputes coverage or denies an item?

Document the insurer's reasons, supply additional substantiation promptly, and follow policy appeal procedures; consider legal or broker assistance if disputes remain unresolved.

Electronic Signature
Templates
Insurance
Insurance Terrorism Cost Form

Insurance Terrorism Cost Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

INSURANCE TERRORISM COST FORM

1. Insurer and Applicant Information

Insurer Name:

Applicant / Insured Mailing Address

Date of Birth

Contact Phone

Agent / Broker

2. Policy and Coverage Details

Policy Number:

Policy Period - From

Policy Period - To

Coverage Type

Terrorism Coverage Endorsement - Included
Terrorism Coverage Endorsement - Excluded

Coverage Limit

Deductible

Premium Attributable to Terrorism

3. Terrorism Cost Allocation and Itemization

Date of Loss or Incident:

Method of Allocation (Select all that apply)

Insured estimate of loss allocable to terrorism
Insurer adjustment / allocation
Allocation per policy endorsement or contract schedule

Provide a detailed itemization of costs directly attributable to the act of terrorism. Include repair, replacement, business interruption losses, emergency response and other related expenses. If additional space is required, attach supplemental schedules and reference them below.

Itemized Costs

1. Description:

Amount:

2. Description:

Amount:

3. Description:

Amount:

4. Additional Items and Total (enter total below)

Total Amount Claimed as Terrorism Loss:

Explanation of Allocation Method and Basis for Amounts Claimed

4. Exclusions and Limitations

The insurer reserves the right to: (a) determine whether an event qualifies as an act of terrorism under the policy language and applicable law; (b) allocate loss between terrorism-covered elements and other causes; and (c) apply any policy exclusions, limitations, sub-limits, or aggregation rules. Payments made under this claim are subject to reduction by any applicable deductible, coinsurance or policy limits.

Applicant must disclose any other insurance, indemnity, or recovery related to the same loss. Failure to disclose other recoveries may result in denial of claimed amounts or recovery of overpayments.

5. Supporting Documentation Checklist

Please indicate which documents are attached or will be supplied upon request. Insurer may require originals for verification.

Photographs of damage
Repair/Replacement Estimates or Invoices
Financial records supporting business interruption losses
Law enforcement or official incident reports
Contracts, subcontracts, vendor invoices
Other (describe below)

If Other, Describe

6. Beneficiary Information (If Claim Proceeds Permit Designation)

If policy proceeds may be directed to a beneficiary, provide designation below. If not applicable, write N/A in printed name.

Beneficiary Name

Relationship to Insured

Percentage of Proceeds

7. Declaration and Certification

I hereby declare that the information and statements contained in this Insurance Terrorism Cost Form and any attachments are true, complete and correct to the best of my knowledge. I certify that amounts claimed are reasonably allocable to damage, loss, or expense arising from the incident identified above and that supporting records are available for inspection.

I authorize the insurer and its representatives to obtain and review records, invoices, contracts, financial statements, and any other documentation necessary to verify the allocation and amount of claimed terrorism-related costs. I understand that the insurer may share claim information with reinsurers, auditors, or governmental authorities as required by applicable law.

I acknowledge that knowingly submitting false or fraudulent information in support of a claim may constitute insurance fraud and may result in denial of benefits, civil recovery, and criminal prosecution under applicable law. I agree to promptly notify the insurer of any recovery or payment received from other sources related to the same loss.

Name and Title of Person Making Declaration If signing on behalf of an entity, state authority to sign

8. Supporting Attachments Reference

List Attachments (include file reference or attachment ID)

Applicant Name:

Signature:

Date:

What the Insurance Terrorism Cost Form Is

The Insurance Terrorism Cost Form documents losses and expenses attributable to a terrorism-related event for the purpose of claim evaluation, allocation, and reimbursement under a policy or government backstop program. It organizes incident details, affected property, estimated remediation or replacement costs, and supporting invoices so insurers and loss adjusters can assess coverage, triggers, and applicable limits. Many carriers require a standardized form to verify cause, segregate terrorism-specific damage from other perils, and support aggregate loss modeling used for reinsurance and federal programs.

Why this form matters for accurate recovery

Completing the Insurance Terrorism Cost Form provides a structured record that helps insurers determine coverage, apply policy sublimits, and allocate costs between property, business interruption, and remediation line items. A clear, complete submission reduces review time and disputes over causation and limits.

Who prepares and signs the form

Parties involved typically include the insured, their broker or risk manager, and the insurer or appointed adjuster.

Insurers and adjusters who need a consolidated cost record for coverage decisions and reinsurance reporting.
Risk managers and brokers who compile claims and coordinate documentation across multiple locations and vendors.
Facilities or asset managers who provide itemized repair estimates, vendor invoices, and loss summaries for the claim.

Core sections to include on a professional form

A complete Insurance Terrorism Cost Form groups incident identification, claim and policy references, itemized cost lines, supporting document checklist, signatory certification, and adjuster notes for efficient review.

Incident ID

Unique identifier for the event and claim number, used to link this form to policy records and any governmental incident declarations.

Policy Data

Policy number, insurer name, coverage period, and specific terrorism endorsement or sublimit details so reviewers confirm applicability and limits quickly.

Cost Breakdown

Itemized categories (structural repair, content replacement, business interruption, debris removal, forensic investigation) with per-line amounts and vendor references.

Supporting Records

List of invoices, contractor estimates, photographs, inspection reports, and permits that substantiate each cost line and the terrorism cause.

Certifications

Signature block where an authorized representative certifies accuracy, damage cause, and any emergency measures taken to mitigate further loss.

Adjuster Notes

Section for insurer or adjuster comments, provisional reserves, disputed items, and recommended next steps for remediation or verification.

Essential data elements at a glance

Insured Name: Full legal entity name

Policy Number: Exact policy identifier

Loss Date: MM/DD/YYYY format

Location: Street, city, state, ZIP

Estimated Cost: Dollar amount per category

Authorized Signer: Name and title

Step-by-step: completing the form

Follow these steps in order to reduce errors and speed insurer review.

01

1. Identify event: Enter incident ID and loss date in MM/DD/YYYY format.
02

2. Attach policies: Record policy number and terrorism endorsement details accurately.
03

3. Itemize costs: List each expense line with vendor and invoice reference.
04

4. Certify and submit: Authorized signer completes certification and routes to insurer.

How to configure the online workflow

Configure your digital submission workflow to capture signatures, required fields, and automated routing for faster insurer processing.

Field	Recommended Setting
Required Fields	Insured name, policy number, loss date, and signature required
Authentication	Email plus SMS code for signer identity verification
Routing	Auto-send to adjuster and broker after signature
Retention	Store signed PDF and audit trail for compliance

Digital signing and submission options

Use an eSignature platform that produces a tamper-evident PDF with an audit trail and supports required authentication levels.

File formats: PDF and DOCX supported
Authentication: Email, SMS, or stronger methods
Integrations: Works with common CRMs and storage

Typical timelines and processing expectations

Timelines vary by carrier and policy terms; use these typical windows to set expectations and follow-up reminders.

Claim Notification Window:

Notify insurer per policy; commonly within 30 days of loss discovery

Adjuster Acknowledgement:

Insurer usually acknowledges receipt within 7–14 business days

Preliminary Reserve:

Initial reserve or decision often set within 30 days of submission

Payment or Denial:

Payments frequently processed within 30–90 days, subject to verification

Appeal Period:

Policy may allow 30–60 days to dispute a coverage decision

Common mistakes to avoid

Incomplete cost breakdowns that mix terrorism and non-terrorism damage often trigger delays while items are separated and verified by adjusters.
Missing vendor invoices or unsigned estimates cause insurers to request substantiation, extending review cycles and delaying payment.
Using inconsistent names or policy numbers between forms, vendor invoices, and the insurance portal can result in misapplied payments or rejected line items.
Failing to certify emergency mitigation actions with dates and vendor receipts may lead insurers to disallow mitigation costs as unsupported.

Consequences of incorrect or late submissions

Claim Denial: Potential partial or full denial

Reserve Adjustment: Lower reserves or delayed payments

Audit Exposure: Increased documentation requests

Reinsurance Impact: Reduced recoveries from reinsurers

Contractual Penalties: Late reporting may breach policy terms

Tax Implications: Incorrect cost treatment affects filings

eSignature vendor comparison for submitting the form

Key vendor criteria for eSigning and secure submission; signNow appears first for feature parity and pricing transparency.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Frequently asked questions about the Insurance Terrorism Cost Form

Answers to common questions about completion, signature validity, supporting documents, retention, and next steps after submission.

Need help? Contact support

What is the primary purpose of this form?
The form consolidates terrorism-related costs into an itemized record for insurer review, reinsurance reporting, and potential government program eligibility; it organizes invoices, estimates, and certifications to support coverage determinations.
Can this form be signed electronically?
Yes. Electronic signatures that meet ESIGN and UETA criteria are acceptable when the platform captures intent, signer attribution, consent, and retains a reproducible record of the signed document and audit trail.
Who must sign the form on the insured side?
An authorized representative with authority to bind the insured—typically a risk manager, officer, or designated claims contact—must sign and date; the signer certifies accuracy of the cost estimates and attached supporting documentation.
What supporting documents should be attached?
Attach vendor invoices, contractor estimates, photographs, inspection reports, permits, payment receipts, and any forensic or security reports that substantiate damage, remediation, and the terrorism cause.
How long should I keep submitted records?
Retain the form and supporting records for the claim lifecycle plus a multi-year period: at minimum three years from filing for tax purposes and six years for HIPAA-regulated health documents where applicable.
What if the insurer disputes coverage or denies an item?
Document the insurer's reasons, supply additional substantiation promptly, and follow policy appeal procedures; consider legal or broker assistance if disputes remain unresolved.

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