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City Of Decatur <br /> TRIA Form <br /> ACrENCY CUST061ER ID_ <br /> ..'..� . <br /> AC�R�° INSURANCE SUPPLEMENT <br /> A4ENl'( CARRIER tA/:L�:f <br /> Arthv J.GaYagher AIX�pecalry Inwrance Car�arry t��33 <br /> hR.;•_.M,sMHER APh..w.0.�7'�rv4NED.l].�ttEL� <br /> Qt:IX3�1M�Ilh! i.fl�Of QEG'iWf.�� <br /> POLIc;YHOLDER DISCLOSURE <br /> FJ4TICE OF TERRORISM INSURANCE COVERAGE <br /> i'ou are hcreby nonfied that under the Terrorism R�sk lnsurance Act,as amended,yrou have a right to purchase <br /> insurence co�erage far los;res resutting from 3cts of tenonsm.As defincd in Section 10^_(1}of ihe Act:The term <br /> �act of terrorism°mear�s any act or acts that are certified by the Sccretary of the Treasury—in consultation with <br /> the Secretary of Hometand Security.and the Attomey General of the United�tates--to be an aci of terrorism.to <br /> be a violent act or an aci that is dangerous to human life,propetry a Infrasiruct��;to have resulied in tlamage <br /> within the Urrted�tates.or ou�.ide the United States in the case of cestain air carri�rs or��ssels or the premises <br /> of a United 5tatee,mission: and ro have lyeen commetted try an individual a indiv�uals as part a#an effort Lo <br /> ccerce the civilian popuiaUon of ihe United States or to influence the policy or affect the con�duct of the United <br /> States Govemmeni by ccercion. <br /> YOU SHQULD KNOW THAT WHERE Cd'iER.�GE IS PRO'IIDED Bt THI� POL1Cti' FOR LOSSES <br /> RESULTING FROM CERTIFIED ACTS OF TERRORISM. :,Uc:H LO�SES MAr�BE PaRTtA.LL�r REIMBURSED <br /> BY THE UNITEd STATE= GOVERNMENT UNDER A FORMULA ESTABLISliED BY FEDERAL LA'JV. <br /> HOWE`:`Ea 'rOUR PO�IC'Y MAY CONTAfN OTHER EkCLU�IONS 'NHICH MIGHT AFFECT 'YOUR <br /> CO'JERi,GE. S�CH AS AN EXCLUSION FOR NUCtEAR E':'ENTS. UNDER THE FORMU�. THE UNITED <br /> �TATES GC3'.'ERtJMENT GENERAILY REIMBURSES 85'�6 THROUGH�15:84°�b BEGINPdIN�ON JANUARY' <br /> 1 201h.83%BEGIPINING ON JANUARY 1,�D17.9�°b BEGINNING ON JaNUA.R'r i,'C�18 81°t6 BE(31NN11*JG <br /> ON JANUAR'v 1, '�di5 anC 80°� BEGINNING ON J+�NUA.RY 1, �D�O. OF C�'�:`EREG TERRt�RISM LOSSES <br /> EXCEEDING THE STATUT�ORILY ESTABtISHE� �EDUCTIBLE PAID 6'r THE i�'tSURiiNCE �CdMPAPJti' <br /> PRp'�:IDING THE CO'';`ERAGE. THE PREMIUM GHARGED FQR THIS CO`.'ERHGE IS PRQ'�'IDED BELOW <br /> AND DC?ES NQT INCLUDE kNY CHARGES FOR THE PC7RTIOfiJ OF LO��� THv.T MAY BE COVERED BY <br /> THE FEDERr1L G�`iERNMENT UNDER THE ACT. <br /> 'rOU SHOULD ALSO KNO'�1 THAT THE TERRORISM RISK IN�URANCE��T.AS AMEP�OED,COPJTAIP�S A <br /> $100 BILLION CAP THAT IIMITS U.S- GC�`:ERNMEhJT REIMBURSEMENT A;, 'JU'ELL AS INSURERS' <br /> LtA.BfLiT'r' FOR LC�SSES RESULTING FROM CER7IFIED ACTS C7F TERRORiS'1�A'vVHEI`J THE AMOUNT OF <br /> SUCH LOSSES IM .4NY`c�NE CALEhlDAR �'EAR E�iCEEDS S1DL�BILU�N_ IF THE A.GGREt�;,TE!FISURED � <br /> LOS.`.:,ES FOR ALL ItJSUt�ER.�i EXCEED 5104 BILLION,YOUR CO','ER,4GE M:,Y 6E REDUCED. <br /> Acceptance or Rejection of Terrorism Insurance Coverag� I <br /> � I hereby elect to purchase terronsm coverage far a prospecti�Je premium cf S ',238 <br /> n I hereby decline to purchase terrorism coverage ior certified acts ofi[eirarism. I�nderstand that'wiil have <br /> no covarage for!o„�s�esulting ftom cerbfied ac�of ternansrn. <br /> Policyholder!Applicant's S ignature Print Name Date <br /> . PdicyFwlder JApplicant's Signature . � Print N.ame . . DaM <br /> Policyiqlder!Applicant's Sipnature Prin[Name Date <br /> Effec4ve Date <br /> Includes copyrighted material of the Natianal Assoaado�of Insurance Commissioners,with its permissan. <br /> ACORD 6�US(2015J01) �2003-2015 ACORD CORP4RATION Alf rights reserved. <br /> The ACORD naane and logo are rrgistered marks of ACORD <br /> Arthur J.Gallagher Risk Management Services,Inc. <br /> 52 <br />