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UH3 A664942 07 1001631 The dollar amount shown for Total Terrorism Premium in the SCHEDULE above represents the sum of premium for Fire Following Premium and Other Than Fire Following Premium. Disclosure of Federal Participation in Payment of Terrorism Losses The United States Government, Department of the Treasury, will pay a share of terrorism losses insured under the federal program. The federal share equals 80% of that portion of the amount of such insured losses that exceeds the applicable insurer retention. However, if aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year, the Treasury shall not make any payment for any portion of the amount of such losses that exceeds $100 billion. Cap on Insurer Participation in Payment of Terrorism Losses If aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year and we have met our insurer deductible under the Terrorism Risk Insurance Act, we shall not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rata allocation in accordance with procedures established by the Secretary of the Treasury. Rejection of Terrorism Insurance Coverage* I 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. Applicant/Policyholder Signature MWITI �a Date *If this policy is a renewal and: Hanover Insurance Com Insurance Company UH3 A664942 07 Quote or Policy Number a. You have previously submitted a signed Rejection, you are not required to submit an additional Rejection at this time; or b. You have previously accepted coverage and now wish to reject, you are required to complete and sign the Rejection of Terrorism Insurance Coverage above. RAMuagmadDlMsian Ww'REVIEWED & APPROVEDBY:401-1374 12 20 Includes copyrighted material of Insurance Services Office, Inc., with its permiss� Risk Management Specialist