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PI-TER-DN1 (1/21) <br />I decline to purchase terrorism coverage. I understand that I will have no <br />coverage for losses arising from "certified" acts of terrorism, EXCEPT as <br />noted above. <br />You, as the Insured, have 30 days after receipt of this notice to consider the <br />selection/rejection of "terrorism" coverage. After this 30 day period, any request for <br />selection or rejection of terrorism coverage WILL NOT be honored. <br />REQUIRED IN GA— LIMITATION ON PAYMENT OF TERRORISMLOSSES (applies to policies which cover <br />terrorism losses insured under the federal program, including those which onlycover fire losses) <br />The provisions of the Terrorism Risk Insurance Act, as amended, can limit our maximum liability for payment of <br />losses from certified acts of terrorism. That determination will be based on a formula set forth in the law involving <br />the national total of federally insured terrorism losses in an annual period and individual insurer participation in <br />payment of such losses. If one or more certified acts of terrorism in an annual period causes the maximum liability <br />for payment of losses from certified acts of terrorism to be reached, and we have satisfied our required level of <br />payments under the law, then we will not pay for the portion of such losses above that maximum. However, that is <br />subject to possible change at that time, as Congress may, under the Act, determine that payments above the cap <br />will be made. <br />INSURED'S SIGNATUR <br />DATE <br />Page 2 of 2 <br />Risk Mw*ganwt D[viaiun <br />REVIEWED 6 APPRavm BY: <br />A+j�x AeWda <br />® <br />Risk Managernent Spetlalist <br />