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Allianz li <br />Please note that any coverage mandated by applicable Workers Compensation laws in your state will not be affected <br />by your rejection below of terrorism coverage. <br />If you have any questions about this or any other insurance matter, please contact your agent or broker. <br />TERRORISM COVERAGE ELECTION: <br />I understand that this offer is conditional on my purchase of coverage for certified acts of terrorism, as defined in <br />The Act, for all policies of insurance which are scheduled in this policy as underlying insurance for this policy that <br />are subject to The Act. I understand that if at a later time it is determined that any of the underlying policies that are <br />subject to The Act do not include coverage for certified acts of terrorism, as defined in The Act, then my election to <br />accept this quote to purchase coverage for certified acts of terrorism, as defined in The Act, will be ineffective. In that <br />event, I also understand that the policy that I am purchasing will have no coverage for losses arising from certified <br />acts of terrorism, as defined in The Act. <br />() I REJECT COVERAGE FOR LOSSES DUE TO CERTIFIED ACTS OF TERRORISM, AS DEFINED IN THE ACT. <br />Applicant: <br />Signature: <br />Title: <br />Date: <br />Insurance Company: <br />Please return to your agent or broker. <br />380141 01 15 <br />Copyright © 2015 Allianz Global Risks US Insurance Company. All rights reserve. <br />�, n RiakMallagnnrnl;D[vlakm <br />4� � /R�EVIEwr,&IMPRO�V/ID BY. <br />MR —Risk Management Analyst <br />