Insurance TRIA & MIP Form

INSURANCE TRIA & MIP FORM

Applicant / Insured Information

Date of Birth:    Tax ID / SSN (if required for policy processing):

Policy Details

Policy Period From:   To:

TRIA Coverage Election

The Terrorism Risk Insurance Act (TRIA) provides a federal backstop for certain certified acts of terrorism. The Applicant must elect whether terrorism coverage is included under this policy. Select the appropriate options and provide the premium breakdown and applicable limits.

  Elect full TRIA terrorism coverage (subject to policy terms and TRIA statutory requirements)

  Elect limited TRIA coverage (insured retains specified exclusion or limitation)

Certification of Understanding:

By selecting TRIA coverage options and signing below, the Applicant certifies that the Applicant understands and accepts that: (a) coverage for certified acts of terrorism is subject to the Terrorism Risk Insurance Act and may be subject to federal program deductibles, co-payments, recoupment mechanisms, and statutory limitations; (b) the carrier will calculate and allocate premiums and potential recoveries in accordance with applicable law and policy terms; and (c) this election supersedes any prior inconsistent elections for the policy period identified above.

MIP (Managed Insurance Program) Declaration

The Managed Insurance Program (MIP) declaration below documents enrollment and participation terms, cost allocation and any program-specific retentions or priority layers. Complete the selections that apply for the policy identified herein.

  Enroll in MIP for this policy period       Exempt from MIP for specific program reasons (explain below)

Coverage Selections and Limits

Select the coverage elements to which TRIA and/or MIP will apply for the stated policy:

  Property (building and contents)     Limit:

  Business Interruption / Extra Expense     Limit:

  Liability (including third-party liability arising from certified acts)     Limit:

  Automobile / Fleet     Limit:

Exclusions and Acknowledgements

The Applicant acknowledges the following exclusions and program limitations. Mark each box to indicate that the Applicant has read and accepts the stated exclusion or limitation.

  Exclusion: War, hostile or belligerent actions not certified as terrorism

  Exclusion: Nuclear and radioactive contamination unless specifically endorsed

  Exclusion: Cyber-related losses unless cyber terrorism endorsement is purchased

  Exclusion: Pollution and contamination losses except where otherwise provided by endorsement

Beneficiary / Payee for Indemnity

If payment under this policy is to be made to a payee other than the insured, provide beneficiary details below.

Documentation Checklist

Attach or provide copies of the following as applicable. Check each item provided.

  Completed application and TRIA/MIP election pages

  Valuation report or proof of insurable values

  Loss history for prior five years

  Physical security or risk mitigation plan (if required)

  Proof of prior terrorism coverage or declination

Declaration and Certification

The undersigned certifies that the information contained in this form and any attachments is true and correct to the best of the undersigned's knowledge and belief. The undersigned acknowledges that material misrepresentation or omission may render the coverage void or subject to denial of claims.

The Applicant authorizes the insurer and its representatives to obtain and verify information from any source necessary to process this election, including but not limited to underwriting, claims history, loss adjustment records and program participation information. The Applicant understands that electing TRIA coverage or MIP participation does not guarantee payment beyond the limits and terms of the policy and applicable statutory provisions.

By signing below the Applicant certifies they have authority to bind the insured entity and that they accept the terms and elections set forth in this form.

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