MEMBER OF

**Great American Insurance Group**

**Great American Professional Risk Insurance Services, Inc.**

**Part of Great American Insurance Group**

11325 N. Community House Road
Suite 200
Charlotte, NC 28277
(704) 364-5161

| Policy Premium: | $128,125.00 |
|----------------|-------------|
| $0.00 Terrorism Included | |
| $128,125.00 | |

**Term:** Annual  
**Rate:** Flat  
**Commission:** 0%

**Terms and Conditions**

**Policy Form:** As per coverage form: U.S. Short Excess Form - Coverage Form (USX8004.02.18) plus the following:

**Our Policy Terms and Conditions:**

* **Attachments:** In Witness Clause (JL7268.09.09)
* **New York Policy Holder Notice - FTZ (SDM841.07.14)**
* **Follow Forms:** Non-Following Form Endorsement- UM/UIM (USX8012.02.18)
* **Terrorism:** Disclosure Pursuant to Terrorism Risk Insurance Act (USX8025.02.18)

**Subjectivities:**

To clarify, please note the conditions of this binder may not be in accordance with the conditions requested in your submission. For complete terms, conditions, exclusions, and limitations, please refer to the policy language itself.

We will add/delete TRIA forms if there are any changes in the Government requirements.

Regards,

**Ashley Hunley - Account Exec., CPCU, CRIS**  
**Great American Professional Risk Ins. Services**

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