2020/21 Terrorism Coverage - Opt-Out NoticePOLICYHOLDER 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 facts 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.
LMA9104
12 January 2015
I hereby elect to purchase coverage for acts of terrorism for a prospective premium of
USD $13,500
X
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
AFB 2623 / AFB 623 Syndicate on behalf of
certain underwriters at Lloyd's
&Wu'x�,
TBD
Print Name
Policy Number
Date
LMA9104
12 January 2015
IMPORTANT NOTICE:
1. The insurance policy that you are applying to purchase is being
issued by an insurer that is not licensed by the State of California.
These companies are called "nonadmitted" or "surplus line"
insurers.
2. The insurer is not subject to the financial solvency regulation
and enforcement that apply to California licensed insurers.
3. The insurer does not participate in any of the insurance
guarantee funds created by California law. Therefore, these funds
will not pay your claims or protect your assets if the insurer becomes
insolvent and is unable to make payments as promised.
4. The insurer should be licensed either as a foreign insurer in
another state in the United States or as a non -United States (alien)
insurer. You should ask questions of your insurance agent, broker, or
"surplus line" broker or contact the California Department of
Insurance at the toll-free number 1-800-927-4357 or internet website
www.insurance.ca.gov. Ask whether or not the insurer is licensed as
a foreign or non -United States (alien) insurer and for additional
information about the insurer. You may also visit the NAIC's internet
website at www.naic.org. The NAIC—the National Association of
Insurance Commissioners—is the regulatory support organization
created and governed by the chief insurance regulators in the United
States.
5. Foreign insurers should be licensed by a state in the United
States and you may contact that state's department of insurance to
obtain more information about that insurer. You can find a link to
each state from this NAIC internet website:
https:Hnaic.org/state_web_map.htm.
6. For non -United States (alien) insurers, the insurer should be
licensed by a country outside of the United States and should be on
the NAIC's International Insurers Department (IID) listing of
approved nonadmitted non -United States insurers. Ask your agent,
broker, or "surplus line" broker to obtain more information about
that insurer.
7. California maintains a "List of Approved Surplus Line Insurers
(LASLI)." Ask your agent or broker if the insurer is on that list, or
view that list at the internet website of the California Department of
Insurance: www.insurance.ca.gov/01-consumers/120-company/07-
lasli/lasli.cfm.
8. If you, as the applicant, required that the insurance policy you
have purchased be effective immediately, either because existing
coverage was going to lapse within two business days or because you
were required to have coverage within two business days, and you did
not receive this disclosure form and a request for your signature until
after coverage became effective, you have the right to cancel this
policy within five days of receiving this disclosure. If you cancel
coverage, the premium will be prorated and any broker's fee charged
for this insurance will be returned to you.
Date: a' (,e
D-1 (Effective January 1, 2020)