Insurance Terrorism Document

INSURANCE TERRORISM DOCUMENT

Insured / Applicant Information

Policy Details

Insurer:    Policy Number:

Terrorism Coverage Election

The Insured must indicate the election regarding coverage for acts of terrorism affecting the insured property or liabilities under the policy listed above. The election below governs application of the insurer's obligation for losses resulting from any act that meets the definition of terrorism set forth in this document.

I elect to ACCEPT terrorism coverage without a separate aggregate cap or sublimit, subject to the policy terms, conditions and any specific terrorism endorsements applied to the policy.

I elect to REJECT terrorism coverage. By rejecting, I understand that losses determined to be acts of terrorism will not be indemnified under this policy.

I elect to ACCEPT terrorism coverage with a specific aggregate cap or sublimit. Cap amount: $ applicable to certified acts of terrorism as defined below.

Definitions, Exclusions and Limitations

Definition of Act of Terrorism: For purposes of this election, an "act of terrorism" means an act, including the use of force or violence or the threat thereof, by any person or group, whether acting alone or on behalf of or in connection with any organization, committed for political, religious, ideological or similar purposes, that causes property damage, bodily injury, financial loss or disruption. A "certified act of terrorism" is an act formally determined to be an act of terrorism by an authorized governmental authority whose determination is relied upon for application of limits, caps, or special conditions under the policy.

Standard exclusions applicable to terrorism coverage election include, but are not limited to: war, undeclared war, civil war, insurrection, government seizure or confiscation of property, acts of national or foreign armed forces, nuclear hazard and pollution where excluded by the policy, and losses arising directly from intentional criminal acts by the insured. Specific policy endorsements may modify or clarify these exclusions.

Where acceptance is elected with a cap or sublimit, such cap is the maximum aggregate liability of the insurer for all covered losses resulting from certified acts of terrorism during the policy period. Payments for losses subject to such cap will be prorated among all covered claimants if aggregate losses exceed the cap.

Premium Adjustment & Notice

Acceptance of terrorism coverage may result in an additional premium. The insurer reserves the right to compute and charge a separate terrorism premium or surcharge based on the coverages provided and the election selected. Payment terms, billing, and the effective date of the elected coverage shall be governed by the policy and insurer billing procedures as set forth in the policy documents.

Claims Reporting and Cooperation

In the event of a loss potentially involving an act of terrorism, the Insured shall give prompt notice to the insurer, preserve all physical evidence insofar as is practicable, furnish proof of loss, cooperate with reasonable investigations, and provide documentation necessary to substantiate the claim. Failure to cooperate or to timely provide required documentation may result in denial or reduction of coverage.

Beneficiary / Payable Parties

Indicate any additional payee, mortgagee, loss payee or beneficiary to whom claims payments should be made (if different from the Insured):

Prior Terrorism Losses

Yes    No

Certification and Acknowledgement

By signing below, the Insured certifies that the election made above is the Insured's informed choice regarding terrorism coverage under the referenced policy. The Insured acknowledges receipt of the terms set forth in this document, understands the differences between acceptance and rejection of terrorism coverage, and acknowledges that election to reject coverage may result in no coverage for losses that are determined to be acts of terrorism. The Insured further represents that the information provided in this form is true and complete to the best of the Insured's knowledge and that any material misstatement may affect coverage or give rise to denial of claims.

The Insured understands that certain acts may be subject to certification by an authorized governmental authority for purposes of applying caps, special procedures or other statutory provisions affecting terrorism losses, and that such determinations may affect coverage, limits and payment procedures under the policy.

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