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The dollar amount shown for Total Terrorism Premium in the SCHEDULE above represents the sum of <br />premium for Fire Following Premium and Other Than Fire Following Premium. <br />Disclosure of Federal Participation in Payment of Terrorism Losses <br />The United States Government, Department of the Treasury, will pay a share of terrorism losses insured <br />under the federal program. The federal share equals 80% of that portion of the amount of such insured <br />losses that exceeds the applicable insurer retention. However, if aggregate insured losses attributable to <br />terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year, the <br />Treasury shall not make any payment for any portion of the amount of such losses that exceeds $100 billion. <br />Cap on Insurer Participation in Payment of Terrorism Losses <br />If aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act <br />exceed $100 billion in a calendar year and we have met our insurer deductible under the Terrorism Risk <br />Insurance Act, we shall not be liable for the payment of any portion of the amount of such losses that <br />exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rate allocation in <br />accordance with procedures established by the Secretary of the Treasury. <br />Rejection of Terrorism Insurance Coverage* <br />I decline to purchase terrorism coverage for certified acts of terrorism. I understand that I <br />will have no coverage for losses resulting from certified acts of terrorism. <br />HANOVER INSURANCE COMPANY <br />Applicant/Policyholder Signature Insurance Company <br />0H3-A140814-10 <br />Print Name <br />Date <br />*If this policy is a renewal and: <br />Quote or Policy Number <br />a. You have previously submitted a signed Rejection, you are not required to submit an additional <br />Rejection at this time; or <br />b. You have previously accepted coverage and now wish to reject, you are required to complete and sign <br />the Rejection of Terrorism Insurance Coverage above. <br />401-1374 12 20 Includes copyrighted material of Insurance Services Office, Inc., with its permise <br />�/ ty <br />Ride Managmient Dh isimt <br />REVIEWED&APPROV®BY: <br />_. <br />- <br />Ruk Manngemen[Spetlzlist <br />