Insurance Terrorism Selection Form

INSURANCE TERRORISM SELECTION FORM

Applicant / Insured Information

Policy Number:    Insurer Name:

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Policy Details

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Terrorism Coverage Selection

The Insured must select one of the following options regarding coverage for losses directly or indirectly caused by, resulting from, or in connection with an act of terrorism. Selection constitutes an amendment to the policy conditions and premium.

Accept terrorism coverage as an endorsement to the policy, subject to the endorsement terms, limits, and an additional premium. I understand acceptance may add a surcharge to the stated premium.

Reject terrorism coverage. I acknowledge that acts of terrorism will remain excluded from coverage under the policy and that this selection may reduce the premium accordingly.

Accept terrorism coverage subject to specified limitations or sub-limits (describe limitations below). I understand limitations will be set forth in an endorsement.

Coverage Components and Options

Select applicable coverage components (additional premium may apply):

Property damage arising from an act of terrorism

Business interruption / contingent business interruption

Extra expense coverage

Loss due to action by public authorities resulting from terrorism

Exclusions and Important Limitations

Unless specifically endorsed, coverage for terrorism shall exclude loss, damage, liability, or expense arising out of: nuclear reaction or radiation; chemical or biological agents; cyber-initiated acts where the proximate cause is a cyber incident not accompanied by physical damage; war, invasion, act of foreign enemy, hostilities; and any act voluntarily caused by the insured. Any endorsement will identify additional exclusions, waiting periods, and sub-limits.

By initialing below, the Insured acknowledges having reviewed the exclusions that apply to the terrorism coverage selection.

Initials:

Beneficiary Designation (If Applicable)

Complete only if the policy requires a beneficiary for payment of proceeds related to terrorism coverage.

Declaration and Certification

I certify that the information provided on this form is true and correct to the best of my knowledge. I acknowledge that my selection on terrorism coverage constitutes an election that will modify the terms, exclusions, and premium of the referenced policy. I understand that if I elect coverage, applicable endorsements will be issued which set forth the precise scope of coverage, any sub-limits, additional exclusions, and premium adjustments. If I decline coverage, I acknowledge that losses arising from acts of terrorism will not be compensable under this policy unless later changed by endorsement.

I authorize the insurer to amend the policy as necessary to reflect this election. I further acknowledge that the insurer may require separate signatures of additional named insureds or interested parties when issuing endorsements.

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