CERTIFIED ACTS AND OTHER ACTS OF TERRORISM
INSURANCE REJECTION FORM

You should read this document carefully and contact us or your agent if you have any questions
regarding insurance coverage for Certified Acts of Terrorism and Other Acts of Terrorism. No coverage is provided by this document.

Under the Terrorism Risk Insurance Act, as amended, you have a right to purchase insurance coverage for losses resulting from acts of terrorism. For information regarding the availability of coverage for Certified Acts and Other Acts of Terrorism, subject to an additional premium, please contact your insurance agent.

The undersigned policyholder or applicant acknowledges and understands that terrorism insurance coverage has been offered pursuant to the Terrorism Risk Insurance Act and its amendments and the policyholder has chosen to reject coverage for Certified Acts and Other Acts of Terrorism.

The rejection of coverage for Terrorism is valid and binding on all insureds and persons claiming benefits under the policy/application.

This rejection of coverage for Terrorism will apply to any renewal, reinstatement, substitute, amended, altered, modified, transfer or replacement policy with this company or with any affiliated company unless the Named Insured makes a written request to the company to exercise a different option.

Your Acknowledgment:

By signing below, I acknowledge that:

1. I intend that my selection will apply to me and to all other persons or organizations that may
be eligible for coverage under this policy.

2. I understand that my selection applies to all subsequent renewals or amendments of my
policy unless I request otherwise in writing.

3. I have read and understand the purpose and content of this form and the consequences of my
selection.

4. I am legally authorized to make decisions concerning the purchase of Terrorism Insurance Coverage.