# POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE

You are hereby notified that under the Terrorism Risk Insurance Act of 2002, including all amendments thereto (the "Act"), you have a right to purchase insurance coverage for losses arising out of certified acts of terrorism as defined in the Act. The term "certified act of terrorism" means any act that is certified by the United States Secretary of the Treasury, in consultation with the Secretary of Homeland Security and United States Attorney General, to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of an air carrier or vessel or the premises of a United States mission; and to have been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion.

YOU SHOULD KNOW THAT WHERE COVERAGE IS PROVIDED BY THE SUBJECT POLICY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM, SUCH LOSSES MAY BE PARTIALLY REIMBURSED BY THE UNITED STATES GOVERNMENT UNDER A FORMULA ESTABLISHED BY FEDERAL LAW. HOWEVER, THE POLICY MAY CONTAIN OTHER EXCLUSIONS WHICH MIGHT AFFECT COVERAGE, SUCH AS AN EXCLUSION FOR WAR OR NUCLEAR EVENTS. UNDER THE FORMULA, THE UNITED STATES GOVERNMENT GENERALLY REIMBURSES A PERCENTAGE OF COVERED TERRORISM LOSSES (85% IN 2015, THEN DECREASING 1% PER YEAR, STARTING IN 2016, UNTIL REACHING 80%) EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE INSURANCE COMPANY PROVIDING THE COVERAGE. THE PREMIUM CHARGED FOR THIS COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES FOR THE PORTION OF LOSS THAT MAY BE COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT.

YOU SHOULD ALSO KNOW THAT THE ACT CONTAINS A $100 BILLION CAP THAT LIMITS U.S. GOVERNMENT REIMBURSEMENT AS WELL AS INSURERS' LIABILITY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM WHEN THE AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAR EXCEEDS $100 BILLION. IF THE AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED $100 BILLION, YOUR COVERAGE MAY BE REDUCED. NEITHER WE NOR THE U.S. GOVERNMENT SHALL BE LIABLE FOR PAYING ANY PORTION OF THE AMOUNT OF SUCH LOSSES THAT EXCEEDS $100 BILLION, AND IN SUCH CASE INSURED LOSSES UP TO THAT AMOUNT ARE SUBJECT TO PRO RATA ALLOCATION IN ACCORDANCE WITH PROCEDURES ESTABLISHED BY THE SECRETARY OF STATE.

You are not required to purchase insurance coverage for losses arising out of certified acts of terrorism as defined in the Act.

However, unless you sign and return this form to us on or before thirty days following the effective date of the subject policy rejecting coverage for losses arising out of certified acts of terrorism, the coverage will be included in the policy subject to all of the other policy terms, conditions, limits and exclusions (including, but not limited to, exclusions for war, nuclear events, and acts of terrorism not certified by the Secretary of Treasury), and your premium for this coverage is $736.

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**I HEREBY REJECT COVERAGE FOR CERTIFIED ACTS OF TERRORISM ON BEHALF OF THE SUBJECT APPLICANT/POLICYHOLDER. I UNDERSTAND THAT WE WILL HAVE NO COVERAGE FOR LOSSES ARISING FROM ANY ACTS OF TERRORISM, AND AGREE THAT THE INSURER'S TERRORISM EXCLUSION WILL BE PART OF ANY INSURANCE PROVIDED.**

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Applicant's/Policyholder's Signature: _______________________

Print Name: ____________________________________________

Title: __________________________________________________

Date: _________________________________________________

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