Insurance TRIA Rejection Form

INSURANCE TRIA REJECTION FORM

Client Name:    Policy Number:

APPLICANT / INSURED INFORMATION

Individual   Corporation   Limited Liability Company (LLC)   Partnership   Other:

POLICY DETAILS

Coverage Limit:    Deductible:    Annual Premium:

Policy Period From:    To:    Effective Date of Rejection Election:

TRIA REJECTION ELECTION

By checking the box below and signing this form, the undersigned elects to reject the federal share of terrorism losses under the Terrorism Risk Insurance Act (TRIA) to the extent permitted by law. This election is a binding declaration by the named insured for the policy identified above.

I hereby elect to reject the federal share of terrorism loss payments under TRIA for the coverages indicated below.

Property (including building and contents)   Business Interruption / Civil Authority   General Liability   Commercial Auto   Workers' Compensation   Professional Liability / E&O   Other:

ACKNOWLEDGMENTS AND UNDERSTANDINGS

The undersigned acknowledges and agrees to the following (initial or check each box):

I understand that rejecting the federal share may increase my net uninsured loss for a certified act of terrorism and may reduce or eliminate any federal government reimbursement to the insurer for such loss.

I understand that this election applies only to certified acts of terrorism as defined by TRIA and does not alter coverage for non-certified incidents unless otherwise stated in the policy.

I certify that I am authorized to make this election on behalf of the named insured and that this election is effective for the policy period identified above, unless revoked in writing in accordance with the insurer's procedures.

I understand premiums, policy terms, or availability of coverage may be affected by this election and that any premium adjustments will be reflected by the insurer as permitted by law and policy terms.

EXCLUSIONS AND LIMITATIONS

The insured acknowledges the following typical exclusions or limitations may apply whether or not the federal share is accepted: nuclear, radiological, chemical or biological incidents where excluded by policy language; losses not certified by the appropriate federal authority; losses subject to war exclusions or policy endorsements that remove terrorism coverage. The undersigned has reviewed the policy language and any relevant endorsements.

I acknowledge that I have read and understand the exclusions and limitations described above.

BENEFICIARY / PAYEE INFORMATION (IF APPLICABLE)

Relationship:    Allocation Percentage:

SUPPORTING INFORMATION

DECLARATION AND CERTIFICATION

I certify under penalty of law that the statements and information contained in this TRIA Rejection Form are true and complete to the best of my knowledge. I understand that making a materially false statement may subject me to denial of coverage, rescission of policy benefits, and other remedies available under the policy and applicable law. I further acknowledge that this election will be recorded by the insurer and will be effective as specified above unless revoked in writing in accordance with insurer procedures.

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