# Ohio Casualty Umbrella/Excess

## Policyholder Disclosure Notice of Insurance Coverage for Certified Acts of Terrorism

Upon receipt of your signed rejection notice, we will endorse your policy to exclude Terrorism Coverage for the current policy term, returning premium or adjusting your account balance, subject to a Minimum Premium, as appropriate. In addition to adjusting the terrorism premium, we will attach a terrorism exclusion to your policy.

Before making a decision to reject terrorism insurance, refer to the Underlying Coverage Requirement located at the end of this Notice.

- **I hereby reject Terrorism Coverage for this policy and elect to have the exclusion for Terrorism Coverage added. I understand that I will have no coverage for losses arising from acts of terrorism.**

**Policyholder/Applicant's Signature:** ___________________________

**Print Name:** ________________________________________________

**Date Signed:** _________________________________________________

**Named Insured:** INTERNATIONAL BUSINESS MACHINES CORPORATION

**Policy Number:** ECO (14) 54 08 82 46

**Policy Effective/Expiration Date:** From 05/21/2013 To 05/21/2014

## Underlying Coverage Requirement

This policy will apply to Terrorism Coverage only in excess of the total amounts stated as the applicable limits of the underlying policies listed in the Schedule of Underlying Insurance and the applicable limits of any other insurance providing coverage to you during the Policy Period.

If you fail to comply with this Underlying Coverage Requirement and you do not maintain your underlying limits as scheduled, we will only be liable to the same extent that we would have been had you fully complied with this requirement.

Attn: Commercial Umbrella & Excess Liability - Terrorism  
P.O. Box 188060  
Fairfield OH 45018

NP 73 12 01 08  
Page 2 of 2