Insurance TRIA Notice

Insurance TRIA Notice

Insured and Policy Identification

Policy Number:    Insurer:

Date of Birth (if individual insured):    Producer/Broker:

Policy Period and Coverage Summary

Policy Period From:    To:

Commercial Property    Commercial General Liability    Workers' Compensation

Terrorism coverage included under the policy    Terrorism coverage excluded from the policy    Terrorism coverage limited to certified acts only

TRIA Notice — Statutory Disclosure and Claim Certification

This notice is provided to the insured to disclose material information concerning federal support available for insured losses arising from acts of terrorism under the federal terrorism risk insurance program. Federal assistance for insured terrorism losses is available only for losses that are certified as losses arising from an act of terrorism pursuant to the statutory program. The availability of federal participation is subject to all statutory conditions, including aggregate industry loss triggers, certification procedures and limitations set forth by statute and implementing regulations.

Insured acknowledges and agrees that: (a) coverage for losses resulting from an act of terrorism may depend on whether the loss is a "certified act of terrorism" as defined under the applicable statute; (b) if certification is made, federal reimbursement of a portion of the insurer's losses may be applied subject to statutory terms; and (c) the insurer may require the insured to provide additional information and to cooperate with investigations and the claims certification process.

The insured must cooperate fully with any insurer request for documentation, sworn statements or other information necessary to support a claim and to assist the insurer in seeking certification. A claim for loss that may involve an act of terrorism should be promptly reported to the insurer in accordance with the policy's notice requirements and must include all relevant factual information regarding the event and the resulting damage or injury.

Exclusions and Sublimits

The following exclusions or sublimits may apply to terrorism-related coverage under this policy. Check items that apply to this policy.

Nuclear, biological or chemical incidents exclusion applies    War, warlike actions or intentional hostile acts exclusion applies

Cyber-related incidents exclusion applies    Pollution or contamination exclusion applies

Claims Information (if reporting a terrorism-related loss)

Date of Loss:    Time of Loss (if known):

Photographs of damage    Repair estimates/invoices    Law enforcement reports

Beneficiary / Additional Interest

Declaration and Certification

By signing below, the undersigned insured certifies that the information provided in this Insurance TRIA Notice is true, complete and accurate to the best of the insured's knowledge. The insured acknowledges that the insurer may rely on this information in the handling and adjustment of any claim and in the submission of any materials required for determination of whether an event is a certified act of terrorism under the federal program.

The insured understands that submission of information does not itself constitute or guarantee certification of an act of terrorism and that federal participation, if any, is determined according to statutory criteria. The insured further agrees to cooperate with the insurer and with any governmental authority in connection with any investigation or certification process.

The undersigned authorizes the insurer to disclose to governmental authorities and to reinsurers any relevant information necessary for handling, adjustment and potential certification of the claim or for seeking federal reimbursement under the applicable program.

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