Insurance Terrorism Offer Form

Insurance Terrorism Offer Form

Purpose: This form documents an offer of supplemental terrorism coverage to the insured under the referenced policy. The insured must affirmatively accept or decline the offered coverage. If accepted, the terms below become a binding endorsement to the underlying policy subject to the conditions, exclusions, limits, and premium stated herein.

Applicant / Insured Information

Policy Details and Coverage Options

Coverage Type (check all that apply):

Property Damage Business Interruption Liability Other

Premium Billing: The estimated additional premium will be billed in accordance with the billing terms of the underlying policy. Acceptance of this offered coverage authorizes the insurer to amend the premium and endorsement the policy for the stated period.

Offer Election

Please indicate election below by marking one box. By selecting Accept, the insured acknowledges receipt of this offer and consents to the issuance of the terrorism coverage endorsement subject to the terms and premium specified above.

I ACCEPT the supplemental terrorism coverage as described above.

I DECLINE the supplemental terrorism coverage at this time.

Exclusions, Definitions, and Limitations

Definitions: For purposes of this endorsement, "Terrorism" means an act or acts of one or more persons, whether acting alone or on behalf of or in connection with any organization or government, involving the use of force or violence and/or the threat thereof, or any other means, for political, religious, ideological or similar purposes, and which is intended to coerce or intimidate a civilian population or to influence the policy or conduct of any government by intimidation or coercion.

Exclusions: This supplemental coverage does not apply to loss or damage arising out of nuclear reaction, radiation, or radioactive contamination; war (declared or undeclared), hostile or warlike action by a sovereign nation; cyber acts unless specifically endorsed; dishonest or criminal acts of the insured; and other exclusions set forth in the underlying policy that are applicable to this endorsement. Coverage is further subject to the certification or non-certification of an act as terrorism under applicable statutory authority where required.

Limitations: Where coverage is subject to a single loss or aggregate limit, payments for terrorism-related loss will reduce available limits for other coverage as set forth in the policy and endorsement. In the event of conflict between this form and the policy, the endorsement issued upon acceptance will govern the terrorism coverage.

Beneficiary / Payee (If Applicable)

Complete only if the policy provides a death benefit or designated payee for terrorism coverage proceeds.

Required Documentation / Supporting Information

Declaration and Certification

By signing below, the undersigned certifies that the information provided on this form is true and complete to the best of their knowledge. The insured understands that acceptance of this offer binds the insurer to issue an endorsement amending the underlying policy to include the terrorism coverage described, subject to the policy terms, limits, exclusions, and the payment of any additional premium due. The insured acknowledges that willful misrepresentation, omission, or fraud may result in denial of coverage and may void the endorsement.

The insured also acknowledges that the insurer retains the right to amend, withdraw, or adjust the offered coverage before issuance of the endorsement in the event of actuarial, regulatory, or underwriting requirements. Acceptance does not take effect until any required premium is paid and the insurer issues the formal endorsement.

Sign Now