Can the disclosure be signed electronically?

Yes. Under the ESIGN Act (15 U.S.C. ch. 96) and state UETA adoption, most disclosures can be validly executed electronically provided intent, consent, attribution, and record retention requirements are met.

What if the insured refuses terrorism coverage?

Record the insured’s declination on the disclosure and retain the signed form in the policy file. Declination documents help defend against later coverage disputes.

Is a notary required for the disclosure?

Generally no. Notarization is not typically required for an insurance disclosure unless state law or a specific policy endorsement expressly requires it.

How should premium changes be documented?

Show the premium impact as a specific dollar amount or percentage on the form and in the policy endorsement. Clear documentation reduces reconciliation issues during billing.

Who must sign the disclosure?

An authorized representative of the insured or its designated agent should sign. The signer’s title and authority should be recorded to ensure enforceability.

What if there is a discrepancy with the policy?

Keep both the disclosure and the controlling policy language. Claims or underwriting disputes will be resolved by comparing the disclosure, endorsement text, and policy declarations.

Electronic Signature
Templates
Insurance
Insurance Terrorism Disclosure Form

Insurance Terrorism Disclosure Form

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

INSURANCE TERRORISM DISCLOSURE FORM

Insurer Name: Client Name:

APPLICANT / INSURED INFORMATION

Insured Full Legal Name Mailing Address

Policy Number

Date of Birth

Contact Telephone

Email Address

POLICY DETAILS

Policy Type: Property Commercial Property General Liability Business Interruption Workers' Compensation Other

Terrorism Coverage Limit

Terrorism Deductible

Terrorism Premium Charge

Policy Period From to

TERRORISM COVERAGE ELECTION

The insurer offers coverage for loss or damage resulting from acts of terrorism subject to the terms, limitations and exclusions of the underlying policy and any applicable endorsement. Applicant must elect whether to include such coverage. Election of coverage will become effective only if and when the insurer issues and attaches the required endorsement to the policy.

I elect to accept terrorism coverage as described below and authorize issuance of the applicable endorsement.
I decline terrorism coverage. I understand that if I decline, losses caused by acts of terrorism identified in the policy and endorsements will not be covered.

If accepting coverage, select the scope of coverage being requested (if applicable):

Coverage for acts of terrorism as certified under applicable statute or regulation Coverage for non-certified acts of terrorism (subject to policy terms and additional premium) Limited coverage subject to per-occurrence or aggregate limits specified in the endorsement

Additional Coverage Instructions or Limitations

EXCLUSIONS AND LIMITATIONS

Except as may be expressly modified by endorsement, the following exclusions and limitations apply to terrorism coverage: the insurer will not pay for loss or expense caused directly or indirectly by war, undeclared war, civil war, insurrection, rebellion, revolution, or seizure or nationalization by a government authority; loss or damage resulting from nuclear reaction, radiation or radioactive contamination; losses arising out of acts committed with the purpose of influencing government policy where the act is not otherwise a terrorist act as defined in the endorsement; losses attributable to dishonest, fraudulent or criminal acts by the insured; and losses excluded by the policy's other provisions. The endorsement may further define "terrorism" and set forth any certification requirements for coverage.

I acknowledge that I have been provided with the material terms of the terrorism coverage, including exclusions and limitations, and that those terms will be set forth in the policy endorsement if coverage is elected.

Applicant acknowledges receipt of the exclusions and limitations described above.

PREMIUM IMPACT AND PAYMENT

Inclusion of terrorism coverage may result in an additional premium or change to the policy premium. The additional premium shown below will apply for the selected coverage and will be charged in accordance with the policy billing terms.

Additional Premium for Terrorism Coverage Payment Terms

BENEFICIARY DESIGNATION (IF APPLICABLE)

If the policy provides payable benefits to a beneficiary, designate one or more beneficiaries below. Percentages must total 100%.

Primary Beneficiary Name

Relationship

Percentage

Contingent Beneficiary Name

Relationship

Percentage

DISCLOSURE AND CERTIFICATION

By signing below, the applicant certifies that the information contained in this Disclosure is true and complete to the best of the applicant's knowledge. Applicant acknowledges receipt of the terms describing terrorism coverage, including applicable exclusions, limitations, and premium impact. Applicant understands that election of coverage will be effective only when the insurer issues an appropriate endorsement and that the endorsement will control the scope of any coverage provided.

Applicant further authorizes the insurer to record this election on the policy and to charge any additional premium resulting from the election in accordance with the policy and billing terms. Applicant understands that declining coverage will leave the policy unchanged and that losses arising from acts of terrorism defined and excluded by the policy will not be covered.

Additional Remarks (optional)

Printed Name:

Signature:

Date:

What the Insurance Terrorism Disclosure Form Is

The Insurance Terrorism Disclosure Form is a written statement provided by an insurer or producer that describes whether terrorism coverage is included, excluded, or offered as a separate option under a property or casualty policy. It explains premium impact, applicable policy endorsements, and any limits or sub-limits specific to acts of terrorism. The form typically accompanies policy applications, renewals, and binders so applicants and insureds can confirm whether coverage applies to terrorism-related losses and understand how elections affect overall coverage and cost.

Why the Disclosure Matters for Insureds and Carriers

A clear terrorism disclosure ensures insureds know whether terrorism risks are covered and how premium and limits change if coverage is elected or declined. For carriers, it documents consumer choice and supports underwriting, claims handling, and regulatory compliance, reducing disputes about coverage scope in the event of a terrorism-related loss.

Who Typically Completes or Receives This Disclosure

Typical participants include insurance producers, underwriting staff, policyholders, and risk managers who handle commercial or high-value properties.

Insurance brokers and agents — prepare and present terrorism coverage options during application and renewal; document insured election and carrier response.
Commercial policyholders and risk managers — decide whether to accept, decline, or separately purchase terrorism coverage for property portfolios.
Underwriters and claims managers — rely on the disclosure for policy interpretation, premium calculation, and claim adjudication.

Retain the completed disclosure with the policy file and share copies with authorized signers to avoid later disputes over terrorism coverage choices.

Step-by-step: Completing the Form

Follow these sequential steps to fill out the disclosure accurately and create a record of the insured's choice.

01

Step 1: Identify the policy and insured information.
02

Step 2: Confirm whether terrorism coverage is offered.
03

Step 3: Mark elected option and note premium impact.
04

Step 4: Have authorized signer sign and date.

Frequently asked questions and common issues

Answers to frequent questions help reduce errors and clarify how the disclosure interacts with policy language and electronic execution.

Need help? Contact support

Can the disclosure be signed electronically?
Yes. Under the ESIGN Act (15 U.S.C. ch. 96) and state UETA adoption, most disclosures can be validly executed electronically provided intent, consent, attribution, and record retention requirements are met.
What if the insured refuses terrorism coverage?
Record the insured’s declination on the disclosure and retain the signed form in the policy file. Declination documents help defend against later coverage disputes.
Is a notary required for the disclosure?
Generally no. Notarization is not typically required for an insurance disclosure unless state law or a specific policy endorsement expressly requires it.
How should premium changes be documented?
Show the premium impact as a specific dollar amount or percentage on the form and in the policy endorsement. Clear documentation reduces reconciliation issues during billing.
Who must sign the disclosure?
An authorized representative of the insured or its designated agent should sign. The signer’s title and authority should be recorded to ensure enforceability.
What if there is a discrepancy with the policy?
Keep both the disclosure and the controlling policy language. Claims or underwriting disputes will be resolved by comparing the disclosure, endorsement text, and policy declarations.

Typical eSignature vendor comparison for completing the form

Comparison of common vendor features and starting prices useful when choosing an eSignature provider for the Insurance Terrorism Disclosure Form.

	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	Verify with vendor	Verify with vendor	Verify with vendor	Verify with vendor
Bulk Send	Yes (premium tier)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA required)	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year limit	Varies by plan	Varies by plan	Varies by plan

Key data elements usually included on the form

Insured: Name and mailing address

Policy: Policy number and carrier

Coverage: Terrorism coverage election

Premium: Premium amount or percentage

Effective: Effective date MM/DD/YYYY

Signature: Signer name, title, date

Potential risks and consequences of incorrect disclosures

Coverage denial: Claims may be denied

Claim disputes: Increased litigation risk

Regulatory fines: State insurance sanctions possible

Billing errors: Incorrect premium invoicing

Contract breach: Policy interpretation disputes

Reputation: Stakeholder trust erosion

Common preparation errors to avoid

Omitting the policy number or mismatching the insured name, which severs the link between the disclosure and the underlying policy and complicates claims processing.
Failing to record the premium adjustment or using vague language such as 'nominal increase' instead of a specific dollar amount or percentage.
Allowing multiple boxes to be checked for coverage election, creating ambiguity about whether coverage was included, excluded, or offered separately.
Missing the authorized signer’s printed name and title, which undermines the ability to prove the signer had authority to bind the insured.

Essential components of a professional disclosure form

A professional form is concise, shows clear elections, provides premium detail, records authority, and preserves an audit trail for claims and regulatory review.

Clear Elections

Distinct checkboxes for Included, Excluded, or Separate Purchase reduce ambiguity and guide endorsements and billing adjustments.

Monetary Detail

Itemized premium or percentage changes and fee calculations let accounting and claims teams reconcile charges precisely.

Authority Block

Signer name, title, date, and printed organization name document who made the election and the signer’s corporate authority.

Effective Dates

Explicit effective and expiration dates determine the period of coverage and establish timelines for retroactive claims.

Carrier Reference

Carrier and policy identifiers ensure the disclosure is stored with the correct file and carrier database record.

Retention Notes

Recordkeeping instructions for retention periods and where the signed disclosure is filed help maintain compliance.

Typical workflow for issuing and storing the disclosure

A standard operational flow helps ensure the form is completed, signed, and retained alongside the policy.

Issue: Producer or carrier prepares the disclosure.
Present: Provide to applicant at application or renewal.
Sign: Authorized insured signs and dates.
File: Retain with policy records and billing files.

Configuring an online workflow to complete the form

Common workflow settings for digital completion ensure identity verification, routing, and record retention meet corporate and regulatory needs.

Field	Configuration
Authentication	Email, SMS code, or KBA where required
Routing Order	Sequential signing or parallel as needed
Conditional Fields	Show premium fields only when elected
Retention Setting	Auto-store PDF and audit trail

Key timing considerations and when to provide the disclosure

Timely presentation and retention of the form help ensure underwriting and billing align with the insured’s election.

At Application:

Provide disclosure when the application is submitted.

At Renewal:

Re-offer disclosure at each renewal or policy change.

Before Effective Date:

Ensure election is signed prior to coverage effective time.

Amendments:

Execute a new disclosure for mid-term coverage changes.

Retention Start:

Retain signed copy immediately in the policy file.

Practical tips to ensure accurate and defensible disclosures

Following these practices reduces disputes and supports clear underwriting and claims outcomes.

Match names and identifiers exactly

Ensure the insured name, DBA, and policy number match the declarations page and billing systems. Consistency prevents misfiling and helps link claims to the correct policy.

Record specific premium figures

Document the exact premium or percentage impact of the terrorism option instead of ambiguous language. Specific figures speed reconciliation and reduce billing disagreement risk.

Capture signer authority details

Ask signers to include printed name, title, and contact information and retain supporting documentation of their authority to bind the insured when necessary.

Preserve an audit trail

Retain signed PDFs, timestamps, IP logs, and any authentication evidence. A complete audit trail supports enforceability and simplifies regulatory or claim reviews.

Typical signers and their authority

Authorized Agent

A licensed broker or agency representative who completes the disclosure on behalf of the insured and records the agent’s name, license number, and contact details for carrier files and regulatory compliance.

Named Insured

An officer, partner, or authorized signatory of the insured organization who has authority to accept or decline coverage and create binding policy changes reflected in the carrier’s records.

Download formats and supporting documents to attach

Provide and store the disclosure in common formats and include supporting materials that clarify elections and premium calculations.

PDF Format

Save the signed disclosure as a flattened PDF/A where possible to ensure long-term readability and preserve visible signatures and endorsement text.

Editable Copy

Keep an editable DOCX or form template for internal updates and tracking; export a finalized PDF for the policy file and client delivery.

Supporting Schedules

Attach premium calculation worksheets, endorsements, and any underwriting memos that explain limits, sub-limits, or exclusions related to terrorism coverage.

Audit Trail

Include the eSignature provider’s certificate of completion with timestamp, signer IP, and authentication method to document execution.

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