When must the disclosure be provided?

Provide the disclosure at policy binding or renewal so the policyholder has written notice of terrorism coverage options before coverage begins.

Can the disclosure be e-signed?

Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and retention requirements are met.

Is notarization required?

Not typically for TRIA disclosures. State insurance departments may have preferences, but notarization is generally not a standard requirement.

What happens if a policyholder declines coverage?

Record the declination explicitly on the form; the insured remains responsible for the uninsured terrorism risk and documentation assists in future claims handling.

How long should executed disclosures be kept?

Retain with the policy for at least the active term plus three years; certain industries or HIPAA-regulated records require up to six years.

Who should I contact for state-specific rules?

Consult the state insurance department (DOI) or legal counsel for jurisdictional requirements and for any mandatory filing or model disclosure language.

Electronic Signature
Templates
Insurance
Insurance TRIA Disclosure Form

Insurance TRIA Disclosure Form

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

INSURANCE TRIA DISCLOSURE FORM

This form provides the disclosure required under the Terrorism Risk Insurance Act (TRIA) and documents the insured's election regarding terrorism coverage for the insurance policy identified below. The statements and elections on this form are incorporated into the policy record and shall be effective as of the signature date below to the extent permitted by the policy and applicable law.

Applicant / Insured Information

Insured Name Insured Address

Date of Birth

Primary Phone

Email

Policy Information

Insurer Name

Policy Number

Policy Type

Policy Period Start

Policy Period End

Coverage Limit

Deductible

Annual Premium

Covered Lines (select all that apply)

Commercial Property General Liability Workers' Compensation Commercial Auto Other:

TRIA Disclosure Statement

Pursuant to the Terrorism Risk Insurance Act and applicable regulations, the federal government may share in the payment of insured losses resulting from a certified act of terrorism. A certified act of terrorism is an act that is certified as such under the Act and may be subject to statutory thresholds, deductibles and federal recoupment provisions. This disclosure explains the availability of federal involvement and the insured's election options regarding terrorism coverage under the policy identified above. The terms, conditions, limits and exclusions of the underlying policy or endorsement control the extent of coverage for any loss alleged to arise from an act of terrorism.

If a loss is determined to be the result of a certified act of terrorism, the federal government may reimburse the insurer for a portion of losses paid by the insurer, subject to applicable statutory deductibles, co-shares and aggregate industry retention amounts. Such federal participation does not expand coverage beyond the policy's insuring agreement, limits, exclusions or other terms.

Elections Regarding Terrorism Coverage

Please indicate your election below. Only one election should be selected. The election you make will govern the treatment of terrorism coverage for the policy period identified above to the extent permitted by the policy and applicable law.

I elect to purchase terrorism coverage as provided by the policy/endorsement. Additional premium for terrorism coverage (if any): $ I elect to exclude terrorism coverage to the extent permitted by law. I understand this election may reduce the premium by: $ I elect limited terrorism coverage subject to an aggregate cap or special deductible as described in the policy endorsement. Specify cap or deductible:

Exclusions

The following are common categories of loss that may be excluded from terrorism coverage unless expressly included by endorsement. Review your policy for the full set of exclusions and endorsements that apply.

Nuclear, chemical, biological or radiological contamination subject to specific exclusion language.
War, hostilities, civil war, insurrection, rebellion or revolution, except as may be expressly covered by endorsement.
Losses arising out of acts not certified as an act of terrorism under applicable law.
Losses subject to any policy-specific terrorism aggregation clauses, sublimits or special deductibles.

Acknowledgement of Exclusions (select to acknowledge)

I have read and understand the exclusions described above and the policy endorsement.

Beneficiary / Loss Payee (if applicable)

Provide the name and allocation for any beneficiary or loss payee to receive proceeds under the policy, if applicable.

Beneficiary / Loss Payee Name

Relationship to Insured

Allocation %

Certification and Acknowledgement

I certify that I am authorized to sign on behalf of the insured named above. I have read and understand this TRIA disclosure and the policy provisions governing terrorism coverage. My election above is complete and accurate to the best of my knowledge. I understand that this election will be part of the insurance record for the policy identified and that changes may be subject to the insurer's underwriting rules and applicable law. I further acknowledge that federal involvement in the payment of losses under TRIA is subject to statutory conditions including but not limited to certification of an act of terrorism, statutory thresholds, deductibles and federal recoupment provisions.

Additional Notes or Instructions

Signature of Insured or Authorized Representative

Printed Name:

Signature:

Date:

What the Insurance TRIA Disclosure Form Is

The Insurance TRIA Disclosure Form documents whether a commercial insurance policy includes federal terrorism coverage provided under the Terrorism Risk Insurance Act (TRIA) framework and explains how terrorism coverage affects premiums, limits, and deductibles. It is typically used by insurers and brokers to notify commercial policyholders about the availability, scope, and cost implications of terrorism coverage and to record the policyholder’s election or declination of that coverage in writing.

Why the TRIA Disclosure Matters for Commercial Policies

Providing a clear TRIA Disclosure protects both insurer and policyholder by documenting coverage elections and ensuring transparency about premium impact and federal backstop mechanics.

Who Typically Prepares and Signs This Form

The Insurance TRIA Disclosure Form is filled out by insurers, brokers, risk managers, or authorized company signatories when issuing or renewing commercial policies.

Insurance carriers and underwriters who issue terrorism-insurable commercial property or casualty policies.
Brokers and agents who present coverage options and record a client’s acceptance or declination.
Corporate risk managers or authorized officers who make binding elections on behalf of insured entities.

The completed form should be retained by both the insurer and the policyholder as part of the policy file and claims documentation.

Stepwise Completion Process

Follow these sequential steps to populate, verify, and finalize the TRIA Disclosure form for a commercial policy.

01

Prepare Policy Data: Gather policy number, limits, premium and insured legal name.
02

Choose Coverage Option: Mark acceptance or declination and specify limits if accepted.
03

Record Premium Effect: Enter premium change or note pending premium calculation.
04

Sign and Date: Authorized signatory signs and dates the form; retain copies.

Core Components of a Professional TRIA Disclosure

A complete, professional form clarifies essential coverage elements, records election choices, and preserves an auditable record for regulatory and claims purposes.

Policy Identifier

Clear policy number and insurer name that tie the disclosure to the exact insurance contract and eliminate ambiguity during claims or audits.

Coverage Election

An explicit acceptance or declination checkbox plus space to specify elected terrorism coverage limits, deductibles, and any sub-limits.

Premium Disclosure

A line showing the premium increase or separate charge for terrorism coverage, or a clear statement that premium is included in the policy premium.

Legal Notice

Concise statutory language explaining TRIA’s federal backstop and that coverage is subject to the Act and insurer terms.

Signatory Block

Authorized signatory name, title, signature line, and date; indicates who may bind the policyholder organization.

Recordkeeping Note

Space for administrative notes and storage instructions so the insurer and policyholder know retention responsibilities.

Essential Data Fields to Include

Policyholder Name: Exact legal name

Policy Number: Carrier-issued ID

Coverage Election: Accept or Decline

Coverage Limits: Amount and currency

Premium Impact: Dollar or percentage

Signature Date: MM/DD/YYYY

How to Configure an Online TRIA Disclosure Workflow

Configure fields, signer order, and verification steps to ensure the form is completed, signed, and stored correctly.

Field \| Configuration	Field Name \| Required/Optional
Policy Number	Required, single-line text
Coverage Election	Required, checkbox group
Signature Block	Required, sign and date
Admin Notes	Optional, internal use only

Digital Signing and Integration Considerations

Use an eSignature platform that supports secure audit trails, common document formats, and integrations with insurer systems.

File Formats: PDF, DOCX supported
Integrations: Salesforce, NetSuite, Google Workspace
Authentication: Email, SMS, or advanced MFA

Where to Send and How to File the Completed Form

Routing depends on insurer process; ensure both carrier and policyholder receive fully executed copies and that internal systems record the election.

Return to Carrier: Upload to insurer portal or send to underwriting email
Archive for Policy File: Store with policy documents in document management
Provide Copy to Policyholder: Email signed PDF to authorized contact
Log in Claims System: Record election for future claim handling

Typical Timing and When to Issue the Disclosure

Issue a TRIA Disclosure at policy binding or renewal; timing ensures the insured has notice before coverage becomes effective and that elections are documented.

At Application or Quotation:

Provide preliminary disclosure where applicable

At Policy Binding:

Deliver final signed disclosure before coverage effective date

At Renewal:

Reissue disclosure with renewal paperwork

Upon Endorsement Change:

Update disclosure if terrorism coverage terms change

Record Updates:

Retain executed copy in policy file immediately

Key Processing Milestones

Track these stages from issuance through archival to ensure complete documentation and auditability for the policy lifecycle.

01

Document Preparation

Populate fields and verify policy data before requesting signature

02

Signatures Obtained

Capture authorized signatory signature and date

03

Carrier Acknowledgement

Carrier confirms receipt and attaches to policy file

04

Retention and Audit

Archive executed form and log in document management

Common Errors to Avoid

Using abbreviations or informal entity names that do not match the insurer’s legal records, which can cause processing delays or claim disputes.
Leaving the premium impact field blank or marked 'TBD' at binding without a follow-up amendment to record the final amount.
Allowing an unauthorized individual to sign the form; unsigned or improperly signed disclosures may not bind the insured.
Failing to store the signed disclosure with the policy file and claims system, creating retrieval issues during audits or claims.

Risks and Potential Consequences of Inaccurate Disclosure

Coverage Dispute: Inaccurate disclosure may lead to disputes over whether terrorism coverage applied

Claims Denial: Errors could contribute to denial if election is unclear

Regulatory Scrutiny: State insurance departments may investigate repeated noncompliance

Financial Exposure: Unrecorded elections can shift risk back to the insured

Contractual Liability: Misrepresentation may trigger contractual remedies

Audit Findings: Weak recordkeeping can result in negative audit outcomes

Typical Signers and Their Roles

Corporate Risk Manager

A mid- to senior-level manager who evaluates coverage options, coordinates with brokers and legal counsel, and has authority to elect coverage on behalf of the organization.

Insurance Broker

A licensed broker or agent who prepares the disclosure, explains premium impact to the client, and ensures the executed form is returned to the insurer and retained.

Practical Examples of Use

These examples show how organizations document TRIA elections and keep the information aligned with underwriting and claims records.

Tech Data

The broker included a TRIA disclosure with all new commercial property policies

Point: standardized template saved review time
As a result, Tech Data maintained consistent underwriting records across multiple regions and simplified claims intake procedures while ensuring clear coverage elections.

Fertility Centers of Illinois

Facility staff recorded the TRIA election at renewal using an electronic form

Point: signatures captured remotely
The organization archived signed disclosures with patient-related risk files, reducing retrieval time during audits.

Practical Tips for Accurate and Efficient Completion

Adopt consistent processes to reduce errors and ensure the TRIA Disclosure is a reliable contractual and audit document.

Use Standardized Templates

Standardize language and fields across products to reduce legal review time and ensure consistent elections and data capture for underwriting and claims.

Validate Signatory Authority

Confirm the signer has authority to bind the insured; keep a record of delegation or corporate resolution when required by internal controls.

Record Premium Adjustments Precisely

Always enter specific dollar amounts or percentages for premium impact; avoid 'TBD' at binding to prevent later disputes regarding cost allocation.

Maintain Accessible Archives

Store executed disclosures in a searchable document management system where they are linked to the policy and available for audits or claims.

eSignature Vendor Comparison for Completing Disclosures

Compare common vendor pricing and features relevant to signing and storing Insurance TRIA Disclosure Forms; signNow is listed first per vendor comparison standards.

	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 credit card	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No envelope cap	Limit: 100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently Asked Questions About the TRIA Disclosure

Answers to common operational and legal questions about completing, signing, and retaining Insurance TRIA Disclosure Forms.

Need help? Contact support

When must the disclosure be provided?
Provide the disclosure at policy binding or renewal so the policyholder has written notice of terrorism coverage options before coverage begins.
Can the disclosure be e-signed?
Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and retention requirements are met.
Is notarization required?
Not typically for TRIA disclosures. State insurance departments may have preferences, but notarization is generally not a standard requirement.
What happens if a policyholder declines coverage?
Record the declination explicitly on the form; the insured remains responsible for the uninsured terrorism risk and documentation assists in future claims handling.
How long should executed disclosures be kept?
Retain with the policy for at least the active term plus three years; certain industries or HIPAA-regulated records require up to six years.
Who should I contact for state-specific rules?
Consult the state insurance department (DOI) or legal counsel for jurisdictional requirements and for any mandatory filing or model disclosure language.

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