EFTA01221758.pdf

Mrshall INSURANCE General Liability Insurance Renewal Proposal Underwritten by certain underwriters at Lloyd's (BRT) For Financial Trust Company, Inc. Page 2 of 2 The coverage in this proposal is of course subject to further terms, conditions and exclusions that will be contained in the policy documents. Total Annual Premium: $3249.17 Including lax Terrorism Coverage Premium: $177.01 including tax THIS QUOTE IS VALID UNTIL: 06/29/12 Stop Gap Premium: $505.00 including tax Check appropriate box for desired coverage: I I 1accept the certain underwriters at Lloyd's General Liability Proposal excluding terrorism coverage I accept the certain underwriters at Lloyd's General Liability Proposal including terrorism coverage I I Accept the Stop Gap Insurance for the additional premium noted above Signature: Date: Az_ EFTA01221758  POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE You are hereby notified that under the TerrorismRisk Insurance Act of 2002, as amended ("TRIA"), that you now have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act, as amended: The term "act of terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States-to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of an air carrier or vessel or the premises of a United States mission; and to have been committed by an individual or individuals, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. Any coverage you purchase for "acts of terrorism" shall expire at 12:00 midnight December 31, 2014, the date on which the TRIA Program is scheduled to terminate or the expiry date of the policy whichever occurs first, and shall not cover any losses or events which arise after the earlier of these dates. YOU SHOULD KNOW THAT COVERAGE PROVIDED BY THIS POLICY FOR LOSSES CAUSED BY CERTIFIED ACTS OF TERRORISM IS PARTIALLY REIMBURSED BY THE UNITED STATES UNDER A FORMULA ESTABLISHED BY FEDERAL LAW. HOWEVER, YOUR POLICY MAY CONTAIN OTHER EXCLUSIONS WHICH MIGHT AFFECT YOUR COVERAGE, SUCH AS AN EXCLUSION FOR NUCLEAR EVENTS. UNDER THIS FORMULA, THE UNITED STATES PAYS 85% OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE INSURER(S) PROVIDING THE COVERAGE. YOU SHOULD ALSO KNOW THAT THE TERRORISM RISK INSURANCE ACT, AS AMENDED, CONTAINS A $100 BILLION CAP THAT LIMITS U.S. GOVERNMENT REIMBURSEMENT AS WELL AS INSURERS' LIABILITY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM WHEN THE AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAR EXCEEDS $100 BILLION. IF THE AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED $100 BILLION, YOUR COVERAGE MAY BE REDUCED. THE PREMIUM CHARGED FOR THIS COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES FOR THE PORTION OF LOSS COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT g U t hereby elect to purchase coverage for acts of terrorism for a prospective premium of S177.01 I hereby elect to have coverage for acts of terrorism excluded from my policy. I undue;..,... : t I will crage for losses arising from acts of terrorism. Policy older/Ap Syndicate of behalf of certain underwriters at Lloyd's errar?dien4"4 BRG10292 Print Name Policy Number _OA Date a//z 21/12/07 LMA9011 Form approved by Lloyd's Market Association EFTA01221759