PL & GL for Medi Spas, Beauty Salons, Gyms

1. MEDI-SPA APPLICATION Phone: State: State: State: Applicant Name: Business Name: Email Address: Mailing Address: City: Business Address #1: City: Type of Facility? Business Address #2: City: Type of Facility? Business operated as: ? Corporation ? LLC ? LLP ? Partnership ? Individual ? Independent Contractor Business operated as Medi-spa? ? Yes ? No If not, other: Website: Zip: Zip: ?Square Feet Zip: ?Square Feet Annual gross receipts from all operations? Total number of procedures performed annually? Do all professionals have licenses? ? Yes ? No How long in business? Products liability needed for products sold by you? ? Yes ? No Gross receipts (excluding private label) Do you private label products for sale ? Yes ? No This requires a separate application Do you want to include General Liability ? Yes ? No If yes, provide Square Feet above ? Will you have other operations you do not wish to cover on this policy? If yes please provide details: Yes No Do you have: Saunas/Steam Rooms? Soaking Pools? Showers? I. BEAUTY SERVICES Category – Pick the best ONE for each technician based on definitions below. Beauticians Massage Aesthetician Medical Aesthetician Yes Yes Yes No If yes, # to Insure:______ No If yes, # to Insure:______ No If yes, # to Insure:______ Number to be Insured TOTAL NUMBER OF OPERATORS Are any of the technicians above covered for other medispa services on this policy? If so, list technician names: ___________________________________________________________________________________________________________ DEFINITIONS: * BEAUTICIANS: Hair, Nails, Eyelash & Brow Enhancements, Waxing, Threading, Topical Makeup Application * MASSAGE: Massage, Body Wraps, Endermologie, Reiki * AESTHETICIANS: All Beautician services AND Facials, Aesthetic Peels, Body Wraps, Massage, Electrology, Microdermabrasion, Ear Piercing, Airbrush Tanning, Ear Candling, Aesthetic Body Treatments * MEDICAL AESTHETICIANS: All Beautician, Aesthetician Services AND Needling/MCA, Medical Grade Peels, LED/Microcurrent, Non-invasive Ultrasound, Radio Frequency, Dermaplaning, Ear Candling 1.1 Have you ever been trained in massage? 1.2 If applying for medical aesthetician, do you use Levulan? 1.3 Do you use a consent form for medical peels? 1.4 Do you want coverage for sexual abuse? (If yes choose limit) $50,000 Aggregate/$25,000 Claim $100,000 Aggregate/$50,000 Claim _______________ Yes Yes Yes Yes No No No No $200,000 Aggregate/$100,000 Claim

2. FOLLOWING SERVICES REQUIRE SEPARATE APPLICATIONS IF COVERAGE IS NEEDED Category UV Tanning Units Permanent Makeup II. MEDICAL DIRECTOR 2.1 Is there a medical doctor on your staff? 2.2 Give name and degree of your supporting doctor: Number to Insure _________ _________ Category Foot Detox Property Coverage Number to Insure _________ Yes No Yes No Do they work out of your office? Yes No Yes No 2.3 2.4 Do you want to cover your medical director on the policy? If yes, indicate any claims they have had in their medical career: 2.5 Is the doctor a medical director for other facilities? 2.6 If so, should coverage be extended? Number of facilities: For what services: III. LASER/IPL/RADIO FREQUENCY SERVICES 3.1 Do you have everyone sign a consent form? 3.2 Do you use a medical history form on everyone? 3.3 Do you provide goggles or eye shields for all laser/IPL work on faces? 3.4 Are you in compliance with all FDA and state laws as to use of lasers/IPLs/Light devices? On behalf of all laser operators endorsed herein, I understand: 1. The Fitzpatrick Scale. I will not be insured to work on Skin Types V & VI unless I have 6 months of experiencewith Lasers/IPLs.. Yes No Yes No Yes Yes No No We must receive a copy of the form(s) you use. Yes No Yes No 2. It is warranted that for Class III & IV devices goggles must be worn by all people in the room at all times the laser is in use. All reflective surfaces will be covered. 3. Every client must sign a consent & medical history form. No coverage will apply if there is not a signed form on file. 4. For Class IV laser use, the room door will stay locked at all times the laser is in use or a sign must be posted on door: LASER IN USE, DO NOT ENTER 5. I understand there is no coverage for EMLA anesthetic use. 6. No insurance will be offered for the following treatments: i. any raised tissue with its own blood supply (such as moles), ii. Skin that is ulcerated, broken (not intact), blistered or has open sores; iii. Bulging veins,veins or cherry hemangiomas over 1.5 millimeters. 7. I understand coverage for laser hair removal work on individuals under the age of 14 is excluded 8. I understand all new Laser/IPL technicians must have six months experience or thirty hours training to be eligible for laser/IPL coverages Dated Signature of Applicant/Title We prefer you use the carrier approved consent, medical history and aftercare forms that are available at www.medispa-ins.com I will use PPIB forms: Signed: Title: I am submitting my own forms for approval: Signed: Title: No insurance binding can be considered until all forms are approved by PPIB

3. OPERATOR INFORMATION (Laser/IPL/Radio Frequency) OPERATOR TO BE NAMED: 1. Licenses held & license numbers: 2. How long have they been working with these devices? 3 What services do you offer: Laser Hair removal Photo Rejuvenation Tattoo removal Rosacea Skin Tag Removal Veins (up to 1.5mm, spider veins) Nonablative wrinkle reduction Cellulite Reduction Toe Fungus Age/sun spots Smoking Cessation What other services, not listed above, do you offer? Laser Acupuncture Weight Loss Laser allergy services Laser acupuncture Radio Frequency 4. 5. Education in light source equipment: List all information as requested Date Class Title Number of Hours OPERATOR INFORMATION (Laser/IPL/Radio Frequency) OPERATOR TO BE NAMED: 1. Licenses held & license numbers: 2. How long have they been working with these devices? 3 What services do you offer: Laser Hair removal Photo Rejuvenation Tattoo removal Rosacea Skin Tag Removal Veins (up to 1.5mm, spider veins) Nonablative wrinkle reduction Cellulite Reduction Toe Fungus Age/sun spots Smoking Cessation What other services, not listed above, do you offer? Laser Acupuncture Weight Loss Laser allergy services Laser acupuncture Radio Frequency 4. 5. Education in light source equipment: List all information as requested Date Class Title Number of Hours OPERATOR INFORMATION (Laser/IPL/Radio Frequency) OPERATOR TO BE NAMED: 1. Licenses held & license numbers: 2. How long have they been working with these devices? 3 What services do you offer: Laser Hair removal Photo Rejuvenation Tattoo removal Rosacea Skin Tag Removal Veins (up to 1.5mm, spider veins) Nonablative wrinkle reduction Cellulite Reduction Toe Fungus Age/sun spots Smoking Cessation What other services, not listed above, do you offer? Laser Acupuncture Weight Loss Laser allergy services Laser acupuncture Radio Frequency 4. 5. Education in light source equipment: List all information as requested Date Class Title Number of Hours Photocopy this page if covering more than 3 people

4. IV. BOTOX/DERMAL FILLER OPERATOR 4.1 Are you in compliance with all AMA and state laws as to use of Botox & Fillers? 4.2 Do you have everyone sign a consent & medical history form? Yes Yes No No On behalf of all Injectable operators, I understand: 1. I will only have coverage in specified facilities unless the no location limit endorsement is purchased. 2. I will only buy Botox from an approved Allergan wholesaler, Xeomin from an approved Merz wholesaler or Dysport from an approved Medicis wholesaler. 3. Botox coverage is only provided for work on patients over 16. 4. Every client must sign a consent form and no coverage will apply if there is not a signed form on file. 5. No coverage is provided for work on pregnant or nursing women. 6. I understand each technician must have training or 6 months experience to be eligible for injectable coverage Dated Signature of Applicant/Title We prefer you use PPIBs approved consentforms that are available at www.medispa-ins.com I will use PPIB forms: Signed: Title: I will use my own forms: Signed: Title: V. SUPPLEMENTS/VITAMINS/HORMONES 5.1 Name & Degree of Operator: Name & Degree of Operator: Name & Degree of Operator: 5.2 Vitamins & Supplements you are providing B12 B Complex Other (please describe) Chromium Glycine Amino Acids Vitamin C 5.3 Hormone services you are providing Male treatments? Yes No If Yes, what types: Female treatments? Yes No If Yes, what types: BioIdentical Hormones Others: 5.4 Do you provide ingestible vitamins/supplements/hormones/herbs? If Yes, what types: Yes No 5.5 5.6 Do you provide injections of vitamins/supplements/hormones? Do you provide consent forms for the above? Yes No Yes No We must receive a copy of the form(s) you use. We prefer you use PPIBs approved consent and medical history forms that are available at www.medispa-ins.com I will use PPIB forms: Signed: Title: I will use my own forms : Signed: Title:

5. VI. LED/MICROCURRENT/ULTRASOUND/ TEETH WHITENING/HAIR STIMULATION LED/MICROCURRENT 6.1a 6.1b I will have everyone sign a consent form: OPERATOR(s) TO BE NAMED: Have you been trained in LED & Microcurrent equipment: Yes No Signed: Title: ULTRASOUND 6.2a 6.2b 6.2d I will have everyone sign a consent form: OPERATOR(s) TO BE NAMED: Have you been trained in Ultrasound equipment: What services do you offer with Ultrasound: Yes No Signed: Title: TEETH WHITENING 6.3a Total Number of Units to be covered? 6.3a 6.3a 6.3a On behalf of all LED Teeth Whitening technicians, I understand: 1. Every client must sign a consent & dental history form. No coverage will apply if there is not a signed form on file. 2. I understand there is no coverage for any prescription anesthetic use. 3. I understand for coverage to apply only trained technicians will turn on or operate the LED Device. 4. I understand if I treat pregnant women a written doctor’s approval will be on file. Have all operators been trained in LED Teeth Whitening? Do you provide customers with home whitening products? If yes, do you provide written instructions for home use? Yes Yes Yes No No No Signature of Applicant/Title Dated HAIR STIMULATION 6.4a Total Number of Units to be covered? 6.4b 6.4c On behalf of all Hair Stimulation technicians, I understand: 1. Coverage is excluded for any guarantees of hair growth 2. Coverage is available only for units designed specifically for hair stimulation 3. I understand for coverage to apply only trained technicians will turn on or operate the Device. 4. I understand a signed consent and medical history form must be on file for coverage to apply Have all operators been trained in LED Hair Stimulation Devices? Do you use Monoxidil in conjunction with the device? Yes Yes No No Signed Dated:

6. VII. LASER/ULTRASOUND ASSISTED LIPOLYSIS/LIPOSUCTION 7.1 OPERATOR TO BE NAMED: 7.2 Licenses you hold & license numbers: 7.3a How long have you been providing Lipolysis services? 7.3b Device being used for Lipolysis 7.4a How long have you been providing Tumescent Liposuction services? 7.4b Do you provide additional liposuction services that are not Tumescent? 7.5 Education in Lipolysis/Liposcution : List all classes and include certificates of completion and your CV Date Class Title Number of Hours 7.6 What other Lipolysis or Liposuction services do you provide? Must list everything for coverage to be considered: 7.7 7.8 Do you provide fat transfer injections? Do you have everyone sign a consent form? Use of these forms is warranted on the policy. I will use PPIB forms: Yes Yes No No We must receive a copy of the form(s) you use. Signed: Title: I am submitting my own forms for approval: Signed: Title: No insurance binding can be considered until all forms are approved by PPIB VIII. MESOTHERAPY SERVICES 8.1 Do you have everyone sign a consent & medical history form? 8.2 Do you give everyone aftercare? Yes Yes No No Please provide copies of form We prefer you use PPIBs approved consent and medical history forms that are available at www.medispa-ins.com I will use PPIB forms: Signed: Title: I am submitting my own forms for approval: Signed: Title: No insurance binding can be considered until all forms are approved by PPIB On behalf of all Mesotherapy technicians, I understand: 1. All technicians must have training or six months experience to be eligible for Mesotherapy coverage 2. All products used must be purchased from licensed compounding pharmacies (Note only ingredients approved by the company will be covered) Every client must sign a consent form and no coverage will apply if there is not a signed form on file. 5. 6. No coverage is provided for work on pregnant or nursing women. Dated Signature of Applicant/Title

7. IX. SCLEROTHERAPY 9.1 Do you have everyone sign a consent & medical history form? 9.2 Do you give everyone aftercare? Yes Yes No No On behalf of all Sclerotherapy operators, I understand: 1. There is no coverage for work on veins over 1.5mm 2. Each technician must have specific training to be eligible for coverage 3. Coverage is only available for products that are used exclusively for the treatment of spider or varicose veins 4. Every client must sign a consent form and no coverage will apply if there is not a signed form on file. 5. No coverage is provided for work on pregnant or nursing women. Dated Signature of Applicant/Title We prefer you use PPIBs approved consent, medical history and aftercare forms that are available at www.medispa-ins.com I will use PPIB forms: Signed: Title: Iwill use my own forms: X. WEIGHT LOSS & APPETITE SUPPRESSANTS Signed: Title: 10.1 OPERATOR TO BE NAMED: 10.2 Licenses you hold & license numbers: 10.3 Are you in compliance with all FDA and state laws as to weight loss services? Yes No 10.4a Do you have everyone sign a consent form? 10.4b Do you have everyone complete a medical history form? Yes Yes No No We must receive a copy of the form(s) you use. We must receive a copy of the form(s) you use. Use of these forms is warranted on the policy. PROFESSIONAL INFORMATION 10.5 How long have you been performing weight loss services? 10.6 How many approximate patients have you treated for weight loss? 10.7 What is your gross annual income from weight loss services? 10.8 Education in weight loss: List all classes and include certificates of completion and your CV Date Class Title Number of Hours 10.9a What products do you use for weight loss? Other (please describe) HCG Phentermine Lipotropics Phendimetrazine Didrex 10.9b What other weight loss services do you provide? Must list everything for coverage to be considered: We prefer you use the carrier approved consent and medical history forms that are available at www.medispa-ins.com I will use PPIB forms: Signed: Title: I am submitting my own forms for approval: Signed: Title: No insurance binding can be considered until all forms are approved by PPIB

8. XI. HAIR TRANSPLANT & RESTORATION SERVICES 11.1 OPERATOR TO BE NAMED: 11.2 Licenses you hold & license numbers: 11.3 Are you in compliance with all FDA and state laws as to hair loss services? Yes No 11.4a 11.4b Do you have everyone sign a consent form? Do you have everyone complete a medical history form? Yes Yes No No We must receive a copy of the form(s) you use. We must receive a copy of the form(s) you use. Use of these forms is warranted on the policy. PROFESSIONAL INFORMATION 11.5 How long have you been performing hair loss services? 11.6a How many approximate patients have you treated for hair loss? 11.6b What is your gross annual income from hair loss services? 11.7a What systems do you use for hair loss services? Other (please describe) NeoGraft FUE Method Strip Method 11.7b What other hair loss services do you provide? Must list everything for coverage to be considered: 11.8 Education in above systems: List all classes and include your CV Date Class Title Number of Hours 11.9 Do you provide hair loss products? Yes No If Yes, what types: We prefer you use the carrier approved consent and medical history forms that are available at www.medispa-ins.com I will use PPIB forms: Signed: Title: I am submitting my own forms for approval: Signed: Title: No insurance binding can be considered until all forms are approved by PPIB

9. SCHEDULE OF SERVICES Technician Degree or License Type Yrs of Experience DERMAL FILLERS 1. 2. 3. 4. 5. Check All To Be Covered: Botox/ Dysport/Xeomin If yes do you perform any of the following? Hyperhydrosis * Masseters* House Parties* Injectables/Others: Restylane Radiesse Injectables on Hands* Other: __________________________________________________________ *Additional Premium May Apply Degree or License Type Captique Prevelle Silk Zyplast Selphyl /PRP* Latisse Sculptra Juvederm Tear Troughs* Perlane Belotero Technician Yrs of Experience SCLEROTHERAPY 1. 2. 3. 4. 5. Degree or License Type Technician Yrs of Experience MESOTHERAPY 1. 2. 3. 4. 5. Technician Services Provided Yrs of Experience 1. 2. 3. 4. 5. SERVICES OTHER Do you have insurance for the “Other” services listed above? Yes No Do you want the License Action Endorsement for an additional premium of $100? Yes No No Do you want to include coverage for HIPAA Defense? Yes

10. XII - HISTORY: NOTE: All questions m ust be answered.Failure to disclose claims history could invalidate coverage. 12.1 Do you currently have insurance coverage? Yes No If yes, indicate the following: Insurer Policy # Liability Limits Premium Exp. Date If claims made, most recent retroactive date: 12.2 Have you ever had professional liability insured refused, declined, cancelled or accepted on special terms? If yes, provide details on a separate sheet 12.3 Has any liability suit, arbitration or other claim proceeding been brought against you, your business or any applicant for any alleged malpractice? If yes, provide details on a separate sheet 12.4 Do you, or any applicant, have knowledge of an event, circumstance or occurrence prior to the effective date of the proposed policy, or do you foresee that a claim may be brought as a result of said event, circumstance or occurrence? If yes, describe details on a separate sheet 12.5 Has any applicant’s license or certification ever been investigated, limited, revoked, suspended, refused, cancelled or voluntarily surrendered by, or to, any state or federal licensing board or regulatory agency? If yes, provide details on a separate sheet 12.6 Have you ever or any applicant ever been charged or convicted of a criminal offense? If yes, provide details on a separate sheet I understand and agree this Application and any supplements attached hereto will be relied upon for issuance of any policy. I further understand and agree that failure to provide a true and accurate response to the foregoing questions may, at the option of the company, result in the voiding of the insurance issued in reliance on this application and/or denial of claims under any policy issued. I authorize and consent to investigations of information bearing upon moral character, professional reputation and fitness to engage in the activities of my business including authorization to every person or entity, public or private, to release all Lloyd’s of London participating syndicates, any documents, records or other information bearing upon the foregoing. I understand and agree these investigations shall not be confined to information submitted in this application, but shall include any other sources of information deemed relevant by the Company as may be authorized by law. Furthermore, I understand that the policy applied for will apply only to CLAIMS FIRST MADE AND REPORTED to the Company in writing within the period of coverage shown on the certificate of insurance issued with the policy or certificate on the date the policy is canceled or terminated, whichever comes first or as otherwise provided by the policy. Yes No Yes No Yes No Yes No Yes No I understand this insurance is being provided through a surplus lines company and the insurer may not be subject to all the insurance laws and rules in my state and the risk is not protected by the State Insurance Insolvency Fund. THIS APPLICATION MUST BE SIGNED BY APPLICANT WITHIN 30 DAYS OF BINDING. SIGNING THIS FORM DOES NOT BIND THE COMPANY TO COMPLETE THE INSURANCE. COVERAGE BECOMES EFFECTIVE WHEN ACCEPTED BY THE INSURANCE COMPANY DATE APPLICANT SIGNATURE REQUESTED EFFECTIVE DATE LIABILITY LIMIT REQUESTED TITLE Can we email you your policy (usually within 2-3 weeks) One box below must be checked: I ELECT TO PURCHASE TERRORISM COVERAGE AT AN ADDITIONAL PREMIUM Yes No ______________________________@______________ I DO NOT ELECT TO PURCHASE TERRORISM COVERAGE AT AN ADDITIONAL PREMIUM ADDITIONAL INSURED: Certificate Holder (Landlord or Lessor) If necessary, add other names on separate paper. NAME: ADDRESS:

11. Business Owners Application 1.1 Applicant Name: Phone: Business Name: Website: Mailing Address: City: State: Zip: Business Address: County: Square Footage of Business Business operated as: ? Corporation ? Parternship ? Individual ? Independent Contractor 1.2 Business operated as salon? If not, other: 1.3 How long in business? Do all professionals have licenses? 1.4 Do you have operations not listed on the schedule? If yes, provide details: Do you have insurance for these operations? Name of insurance company: PROPERTY SECTION MUST INSURE FOR 100% OF THE REPLACEMENT COST 2.1 Age of building: Construction: Number of stories: 2.2 If building is over 20 years old, when were the following upgraded? (*) Information is Required *Roof: *Plumbing: *Wiring: Sprinklers: 2.3 2.4 *Central Station Burglar Alarm? Yes No If yes advise alarm provider : Other Occupancies in building? (Describe) RIGHT: 2.5 Adjoining Occupancies: LEFT: Distance from fire hydrant: 2.6 Approximate distance from fire station: 2.7 Do you sell clothing? Yes ? No ? If yes, Inventory Value: $ 2.8 Do you sell or use jewelry? Yes ? No ? If yes, Jewelry Value: $ 2.9 Name & address of loss payee: COVERAGES DESIRED CONTENTS – Limit Needed: BUILDING – Limit Needed: EARNINGS – Limit Needed: SIGN – Limit Needed: $ $ $ $ Deductible $1,000 Deductible $1,000 For What Period? ________________ Deductible $100 CLAIMS 3.1 List all property claims in the past 5 years, whether or not insured: 3.2 Current property insurance carrier, policy number:

12. PART IV. HISTORY NOTE: All questions must be answered. Failure to disclose claims history could invalidate coverage. Do you currently have insurance coverage? ___Yes ___No If yes, indicate the following: Insurer Policy # Liability Limits Premium Exp. Date If claims made, most recent retroactive date: List liability claims history arising from any business or other professional activity, whether or not insured: If none, state so_____________ YR/Claim Nature of injuries Equip. Involved Details, if Pending Amt. if settled 4.1 4.2 4.3 Do you have knowledge of an event, circumstance or occurrence (other than listed in 4.2 above) prior to the effective date of the proposed policy, or do you foresee that a claim may be brought as a result of said event, circumstance or occurrence? Yes No. If yes, describe details of the event: I understand and agree this Application and any supplements attached hereto will be relied upon for issuance of any policy. I further understand and agree that failure to provide a true and accurate response to the foregoing questions may, at the option of the company, result in the voiding of the insurance issued in reliance on this application and/or denial of claims under any policy issued. I authorize and consent to investigations of information bearing upon moral character, professional reputation and fitness to engage in the activities of my business including authorization to every person or entity, public or private, to release all Lloyd’s of London participating syndicates, any documents, records or other information bearing upon the foregoing. I understand and agree these investigations shall not be confined to information submitted in this application, but shall include any other sources of information deemed relevant by the Company as may be authorized by law. I understand this insurance is being provided through a surplus lines company and the insurer may not be subject to all the insurance laws and rules in my state and the risk is not protected by the State Insurance Insolvency Fund. THIS APPLICATION MUST BE SIGNED BY APPLICANT WITHIN 30 DAYS OF BINDING. SIGNING THIS FORM DOES NOT BIND THE COMPANY TO COMPLETE THE INSURANCE. COVERAGE BECOMES EFFECTIVE WHEN ACCEPTED BY THE INSURANCE COMPANY DATE APPLICANT SIGNATURE TITLE REQUESTED EFFECTIVE DATE LIABILITY LIMIT REQUESTED ADDITIONAL INSURED: @ $50 Certificate Holder (Landlord or Lessor) If necessary, add other names on separate paper. NAME: ADDRESS: Relationship to your business (Landlord, lienholder):

13. POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE You are hereby notified that under the Terrorism Risk 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 WILL BE PROVIDED IF ACCEPTED, PRIOR TO BINDING. IT WILL NOT INCLUDE ANY CHARGES FOR THE PORTION OF LOSS COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT. I hereby elect to purchase coverage for acts of terrorism for a prospective premium of ______________________ _____________________________ Policyholder/Applicant’s Signature Print Name _____________________________ Date I hereby elect to have coverage for acts of terrorism excluded from my policy. I understand that I will have no coverage for losses arising from acts of terrorism. Underwriter’s at Lloyd’s, London Insurance Company Policy Number