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Insurance Terrorism Rejection Document

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INSURANCE TERRORISM REJECTION DOCUMENT

Insurer Name:   Policy Number:

Applicant / Insured Information

Date of Birth: / /

Policy Details

Property    Liability    Business Interruption    Package    Other:

Policy Period From: / /   To: / /

Terrorism Coverage Election

The undersigned acknowledges that the insurer has offered optional coverage for loss or damage directly or indirectly caused by acts of terrorism. The undersigned elects one of the following (select one):

I elect to REJECT the optional terrorism coverage. By checking this box and signing below, I acknowledge that I have been offered such coverage and that I decline it. I understand and agree that:

• The policy issued or endorsed will contain a terrorism exclusion or will not include the optional terrorism endorsement; and
• Losses arising out of an insured peril that are caused by, contributed to by, resulting from, or related to an act of terrorism, as defined in the policy, are not covered; and
• I remain responsible for all premiums and deductible obligations applicable to my policy notwithstanding this rejection; and
• This rejection is effective for the policy period stated above unless I provide a written request to the insurer to add the coverage during a renewal or change in terms permitted by the insurer.

I elect to PURCHASE the optional terrorism coverage (select only if purchasing). If electing purchase, indicate endorsement details and additional premium below.

Exclusions and Important Notices

The terrorism exclusion or endorsement, as applicable, will describe the scope of excluded acts and may exclude coverage for losses caused by or resulting from:

By signing this document the undersigned acknowledges that they have read and understand the applicable exclusion language, and that electing to reject optional terrorism coverage may reduce or eliminate coverage for certain losses otherwise covered by the policy.

Beneficiary Designation (If Applicable)

Declaration and Certification

I, the undersigned, declare under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. I acknowledge that the insurer offered optional terrorism coverage and that I have been given an opportunity to review the terms, exclusions, and premium impact of that coverage. I further acknowledge that by electing to reject terrorism coverage I accept the risks of noncoverage for loss or damage resulting from acts of terrorism as defined by my policy. I authorize the insurer to place the appropriate endorsement or exclusion on my policy record that reflects my election.

I understand that this election will remain in effect for the policy period specified above unless I submit a subsequent written request in a manner permitted by the insurer to modify this selection during renewal or as otherwise allowed by policy terms.

Printed Name:

Signature:

Date:

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What the Insurance Terrorism Rejection Document Is

The Insurance Terrorism Rejection Document is a formal written record used by a policyholder to decline optional terrorism coverage offered by an insurer. It documents the policyholder's informed decision, records the effective date of rejection, and identifies the affected policy or policies. Insurers typically require a signed rejection when a terrorism endorsement or separate terrorism premium is available but not purchased. The document serves as proof for underwriting, claims handling, and regulatory review, and should be retained with the policy file and any related correspondence.

Why this document matters for policy and risk clarity

A clear rejection form creates an auditable record that the insured knowingly declined coverage, reducing disputes and clarifying premium and claims exposure for both parties under the policy.

Why this document matters for policy and risk clarity

Who typically completes or signs this form

The Insurance Terrorism Rejection Document is completed by the contracting party with authority to change coverage and by intermediaries who facilitate placement.

  • Commercial policyholders and corporate risk managers who control insurance procurement for the entity.
  • Licensed insurance agents or brokers submitting client directions to the carrier.
  • Underwriting or compliance staff within the insurer documenting client election on file.

Maintain a signed copy in the policy file and distribute copies to the broker, insured, and underwriting office as required.

Step-by-step: completing and submitting the rejection document

Follow these sequential steps to complete the Insurance Terrorism Rejection Document so the insurer can process and record the election without delay.

  • 01
    Identify policy: Confirm exact policy number and insured legal name.
  • 02
    Complete fields: Fill insured, policy number, coverage year, and rejection checkbox.
  • 03
    Sign and date: Authorized signer signs and dates in the signature block.
  • 04
    Submit to carrier: Send the completed form to underwriting and retain copies.

Where to send the completed form and how it is processed

Deliver the signed rejection to the insurer and to any broker or agent who placed the policy; insurers will record the election in policy files and premium systems.

  • Insurer underwriting: Submit to the insurer's underwriting or policy administration address on file.
  • Agent/broker: Provide a copy to the placing broker or agent for their records and client file.
  • Policy documentation: Carrier attaches the signed rejection to the insured's policy record and premium ledger.
  • Record retention: Insurer retains the document per internal and regulatory retention policies.

Setting up an online workflow for this form

Use these configuration points when creating a digital workflow to collect rejections reliably and with an audit trail.

Field Online setting
Signature field Required eSignature with timestamp
Checkbox: rejection Required and locked after signing
Date field MM/DD/YYYY format enforced
Attachments Allow supporting documents (PDF only)

Technical requirements for secure eSubmission

Ensure the platform supports secure signatures, audit trails, and integrations so the insurer can ingest the document into policy systems.

  • Authentication: Email + optional SMS code
  • Audit trail: IP, timestamp, and action log
  • Integrations: Connectors to policy admin or CRM

Use a vendor that meets regulatory and carrier requirements and that can deliver a tamper-evident PDF plus a complete certificate of completion.

Common preparation mistakes to avoid

  • Leaving the policy number blank or entering only a partial number, which prevents correct matching to the policy record and causes processing delays.
  • Using an unsigned or undated form, which can render the election non-binding and prompt insurer follow-up or rejection of the instruction.
  • Having an unauthorized signer complete the form, which may be unenforceable and require a corrected form signed by an authorized officer or owner.
  • Failing to attach requested supporting documents when the carrier requires additional verification, resulting in incomplete processing or additional inquiries.

Risks and consequences of improper or missing rejection documentation

Coverage gap: Missing terrorism coverage may leave the insured exposed to losses without compensation.
Premium errors: Incorrect records can cause incorrect premium billing or retroactive adjustments.
Regulatory inquiry: State insurance authorities may request evidence of informed consent or disclosure.
Dispute risk: Claims disputes may arise if the insured later contests the rejection.
Audit trail missing: Lack of verifiable signature and timestamp weakens legal defensibility.
Agent liability: Agents who fail to document client direction may face professional or contractual exposure.

Security and compliance features to require for eSubmission

Encryption: TLS 1.2/1.3 in transit
At-rest encryption: AES-256 at rest
Audit standard: SOC 2 Type II certified
Regulatory: ESIGN and UETA compliant
Health data: HIPAA support with BAA
FDA records: 21 CFR Part 11 capabilities

eSignature vendor pricing and capability snapshot for this workflow

Compare vendor starting prices and core capabilities relevant to processing Insurance Terrorism Rejection Documents; signNow is listed first per comparative layout.

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 No No Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Real-world scenarios where a terrorism rejection form is used

These two brief examples show typical situations and downstream implications.

Case Study 1

A midsize manufacturing company declines optional terrorism coverage to limit premium expense.

  • Broker obtains a signed rejection from corporate counsel.
  • The signed form is attached to the policy and retained; on renewal the company reconsiders coverage after a change in perceived risk.

Case Study 2

A commercial landlord rejects terrorism coverage for a single building to avoid additional premium.

  • Lender reviews the rejection as part of loan conditions.
  • The landlord provides the signed form to both the lender and insurer to confirm the election and avoid future dispute at claim time.

Frequently asked questions about the rejection document

Answers to common questions about legal validity, electronic signing, corrections, and revocation for the Insurance Terrorism Rejection Document.


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