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POLICY NUMBER: <br />IL 09 99 12 20 <br />THIS ENDORSEMENT IS ATTACHED TO AND MADE PART OF YOUR POLICY IN <br />RESPONSE TO THE DISCLOSURE REQUIREMENTS OF THE TERRORISM RISK <br />INSURANCE ACT. THIS ENDORSEMENT DOES NOT GRANT ANY COVERAGE OR <br />CHANGE THE TERMS AND CONDITIONS OF ANY COVERAGE UNDER THE POLICY. <br />DISCLOSURE OF PREMIUM AND ESTIMATED PREMIUM <br />FOR CERTIFIED ACTS OF TERRORISM COVERAGE <br />(PURSUANT TO TERRORISM RISK INSURANCE ACT) <br />SCHEDULE <br />SCHEDULE — PART 1 <br />Terrorism Premium (Certified Acts) <br />(A) Premium through end of year (12/31/ ) $ <br />(B) Estimated Premium beyond the date specified above $ <br />(Refer to Paragraph D. in this endorsement.) <br />This premium is the total Certified Acts premium attributable to the following Coverage Part(s), <br />Coverage Form(s) and/or Policy(ies): <br />All Coverage parts other than: <br />Social Service Professional Liability Coverage Form <br />Business Auto Coverage <br />Additional information, if any, concerning the terrorism premium: <br />SCHEDULE — PART II <br />Federal share of terrorism losses 80 % <br />Refer to Paragraph B. in this endorsement. <br />Information required to complete this Schedule, if not shown above, will be shown in the Declarations. <br />IL 09 99 12 20 C Insurance Services Office, Inc., 2020 <br />w,�ow� <br />11 I�NEWE96 /1ffliP/ED @!: <br />ftkMmag .Clm.IAide <br />r.U. I VI L <br />