POLICYHOLDER DISCLOSURE
NOTICE OF TERRORISM
INSURANCE COVERAGE
You are hereby notified that under the Terrorism Risk Insurance Act of 2002, as amended ("TRIA"), that you
now have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in
Section 102(1) of the Act, as amended: The term "act of terrorism" means any act that is certified by the
Secretary of the Treasury, in consultation with the Secretary of Homeland Security and the Attorney General of
the United States, 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. Any coverage you
purchase for "acts of terrorism" shall expire at 12:00 midnight December 31, 2020, the date on which the TRIA
Program is scheduled to terminate, or the expiry date of the policy whichever occurs first, and shall not cover
any losses or events which arise after the earlier of these dates.
YOU SHOULD KNOW THAT COVERAGE PROVIDED BY THIS POLICY FOR LOSSES CAUSED BY CERTIFIED ACTS OF
TERRORISM IS PARTIALLY REIMBURSED BY THE UNITED STATES UNDER A FORMULA ESTABLISHED BY FEDERAL
LAW. HOWEVER, YOUR POLICY MAY CONTAIN OTHER EXCLUSIONS WHICH MIGHT AFFECT YOUR COVERAGE,
SUCH AS AN EXCLUSION FOR NUCLEAR EVENTS. UNDER THIS FORMULA, THE UNITED STATES PAYS 85%
THROUGH 2015; 84% BEGINNING ON JANUARY 1, 2016; 83% BEGINNING ON JANUARY 1, 2017; 82%
BEGINNING ON JANUARY 1,2018; 81% BEGINNING ON JANUARY 1, 2019 AND 80% BEGINNING ON JANUARY 1,
2020; OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE
INSURER(S) PROVIDING THE COVERAGE. YOU SHOULD ALSO KNOW THAT THE TERRORISM RISK INSURANCE
ACT, AS AMENDED, CONTAINS A USD100 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 USD100 BILLION. IF THE AGGREGATE
INSURED LOSSES FOR ALL INSURERS EXCEED USD100 BILLION, YOUR COVERAGE MAY BE REDUCED.
THE PREMIUM CHARGED FOR THIS COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES
FOR THE PORTION OF LOSS COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT.
I hereby elect to purchase coverage for acts of terrorism for a prospective premium of
USD………………….
I hereby elect to have coverage for acts of terrorism excluded from my policy. I understand that I
will have no coverage for losses arising from acts of terrorism.
Policyholder/Applicant's Signature Syndicate on behalf of certain underwriters at Lloyd's
Print Name Policy Number Date
LMA9104
12 January 2015
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