**SUBJECT TO THE TERMS, CONDITIONS AND LIMITATIONS OF YOUR POLICY, ANY COVERAGE MANDATED BY APPLICABLE STANDARD FIRE POLICY LAWS OR WORKERS COMPENSATION LAWS IN YOUR STATE WILL NOT BE AFFECTED BY YOUR REJECTION BELOW OF COVERAGE FOR TERRORISTS, AS DEFINED IN THE ACT.**

- **I hereby elect to purchase full coverage for acts of terrorism, as defined in the Act, (Certified Terrorism) for a term premium of $3,962.00 plus any applicable surcharges, taxes or fees. I acknowledge that my decision to accept and purchase full coverage for Certified Terrorism shall govern throughout the term of the policy.**

- **I hereby reject the offer to purchase coverage for acts of terrorism, as defined in the Act (Certified Terrorism), and I understand that an exclusion for Certified Terrorism will be included in my policy. I further understand I will have no coverage for losses arising from Certified Terrorism. In addition, I acknowledge that if I reject the offer to purchase this coverage at this time, I will not have another opportunity during the term of the policy to purchase full coverage for Certified Terrorism.**

**Company**
- **Policyholder/Applicant's Signature**
- **Print Name**
- **Date**

**PLEASE RETURN THIS SIGNED DISCLOSURE NOTICE TO YOUR BROKER OR AGENT**

Nothing in this letter should be construed as legal advice to you. Consult your attorney and/or broker or agent to evaluate the terms of this offer.

**AGRL-IL 8T01 (01-15)**

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