2022-06-14 - Declination of Terrorism Insurance Coverage
INTERLINE
EVANSTON INSURANCE COMPANY
POLICYHOLDER DISCLOSURE
NOTICE OF TERRORISM INSURANCE COVERAGE
Date: 06/09/2022
Policyholder/Applicant Name: Costa Mesa Sanitary District
You are hereby notified that under the Terrorism Risk Insurance Act, as amended, you have a right to purchase insurance coverage for
losses resulting from acts of terrorism,as defined in Section 102(1) of the Act: 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 certain air carriers or vessels 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.
YOU SHOULD KNOW THAT WHERE COVERAGE IS PROVIDED BY THIS POLICY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF
TERRORISM, SUCH LOSSES MAY BE PARTIALLY REIMBURSED BY THE UNITED STATES GOVERNMENT 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 THE FORMULA, THE UNITED STATES GOVERNMENT
GENERALLY REIMBURSES 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 INSURANCE COMPANY
PROVIDING THE COVERAGE. THE PREMIUM CHARGED FOR THIS COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY
CHARGES FOR THE PORTION OF LOSS THAT MAY BE COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT.
YOU SHOULD ALSO KNOW THAT THE TERRORISM RISK INSURANCE ACT, AS AMENDED, CONTAINS A $100 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 $100 BILLION. IF THE AGGREGATE
INSURED LOSSES FOR ALL INSURERS EXCEED $100 BILLION, YOUR COVERAGE MAY BE REDUCED.
SELECTION OR REJECTION OF TERRORISM INSURANCE COVERAGE
PLEASE “X” ONE OF THE BOXES BELOW AND TAKE THE ACTION INDICATED.
I hereby elect to purchase terrorism coverage for a prospective premium of $ 1,375.00.
I hereby decline to purchase terrorism coverage for certified acts of terrorism. I understand that I will have no coverage for losses
resulting from certified acts of terrorism.
_____________________________________
Policyholder/Applicant Signature
_____________________________________ _____________________________________
Print Name Date
MKL TERR-4 (01/08) Includes copyrighted material of National Association Of Insurance
Commissioners, with its permission.
Page 1 of 1
Scott Carroll
X
6/14/2022