Form TRIP-02 Terrorism Risk Insurance Program Certification of Loss (

Control Number:____________________
(Treasury use)

TERRORISM RISK INSURANCE PROGRAM
CERTIFICATION OF LOSS
Pursuant to 31 CFR 50.53 this form is to be used by insurers claiming the Federal share of
compensation under the Terrorism Risk Insurance Program for insured losses arising from Program
Trigger Events. The initial, and if necessary, supplemental, Certification(s) of Loss are to include data
relevant to all insured losses paid or that will be paid as specified in 31 CFR 50.53(b)(2)(i) based on all
Program Trigger Events within a Program Year. Schedules A, B, and C (see below) are required
supporting documentation for this Certification of Loss form. Treasury must receive, or have received,
an Initial Notice of Insured Loss for the relevant Program Year in order to process a Certification of
Loss. In order to receive payment of the Federal share of compensation, the insurer must register with
the Terrorism Risk Insurance Program Claims Facility and also be registered in the Central Contractor
Registration (CCR).
Further information can be obtained via the internet at

https://tripclaims.treas.gov.
Insurer or Insurer Group Name: ___________________________________________
NAIC Insurer (or Group) Number (or TIN if no NAIC #): ______________________
Initial ___ or Supplementary ___ Certification

Program (calendar) Year: _________

Data as of: ____/_____/_______ ISO/PCS Cat Code(s) ________ _________ _________ ________
Calculation of Federal Share of Compensation Claimed (*amounts from Bordereau):
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Total Cumulative Losses Paid and To be Paid*
Plus Total Allocated Loss Adjustment Expenses Paid*
Less Punitive Damage Amounts Paid*
Subtotal Insured Losses Paid
Less Total Salvage and Subrogation Recovered*
Subtotal Adjusted Insured Losses Paid
Less Insurer Deductible (from Schedule A)
Subtotal Excess of Deductible
Gross Federal Share (90% of subtotal Excess of Deductible in 2006; 85% in 2007)
Less Excess Insurer Recoveries (see below)
Less Duplicate Federal Recoveries*
Total Net Federal Share of Compensation
Less Prior Claimed Federal Share of Compensation
Federal Share of Compensation due Insurer (due Treasury)1

$ ________________________
$ ________________________
$ ________________________
$ ________________________
$ ________________________
$ ________________________
$ ________________________
$ ________________________
$ ________________________
$ _________________________
$ _________________________
$ _________________________
$ _________________________
$ _________________________

Calculation of Excess Insurer Recoveries (if required):
15. Total Reinsurance Recoveries from Program Trigger Events
16.
Less Recoveries Repaid or to be Repaid to Reinsurers
17.
Subtotal Net Reinsurance Recoveries
18.
Plus Gross Federal Share (line 9)
19.
Subtotal Total Insurer Recoveries
20.
Less Adjusted Insured Losses Paid (line 6)
21. Total Excess Insurer Recoveries (if less than zero, enter zero above)

$ ________________________
$ ________________________
$ ________________________
$ ________________________
$ ________________________
$ ________________________
$ ________________________

OMB No. 1505-0200 Expiration: September 30, 2007
TRIP 02 (revised 07/2006)

Control Number:____________________
(Treasury use)
Supporting Schedules Attached (check all that apply):
____ Schedule A: Declaration of Direct Earned Premium and Insurer Deductible
(Required unless already submitted with Initial Notice of Loss)
____ Schedule B: Certification of Compliance (Required)
____ Schedule C: Loss Bordereau (Required)
Certification
I hereby certify that the statements, data, calculations and supporting documentation used to determine
the Total Federal Share of Compensation claimed herein are accurate and complete to the best of my
information, knowledge and belief. Any false or fraudulent statements or claims may subject the
insurer and signatory to criminal, civil, or administrative penalties.
__________________________

____________________________

Name

_____________________

Officer Title

Date

___________________________
Signature

Notice Under the Paperwork Reduction Act
We estimate it will take you about 90 minutes to complete this form. However, you are not required to
provide information requested unless a valid OMB control number is displayed on the form. Any
comments or suggestions regarding this form should be sent to the Terrorism Risk Insurance Program
Office, 1425 New York Avenue, NW, Washington, DC 20220. Do not send completed form to this
address. Submit forms according to instructions provided at www.treas.gov/trip.

_______________________________
1

When the insurer is required to reimburse Treasury, payment may be remitted by check or wire transfer. Checks
should be made payable to U.S. Treasury and addressed to Department of the Treasury, Office of Financial
Management, Attn: Metropolitan Square, 6th Floor, 1500 Pennsylvania Ave., NW, Washington, DC 20220.
Wire transfers should be made to ABA number 021030004, Account number 20010001. Please provide a brief
description/identification number in the comments area.

OMB No. 1505-0200 Expiration: September 30, 2007
TRIP 02 (revised 07/2006)