TRIP-01 Inititial Notice of Insured Loss

Control Number:______________________
(Treasury use)

TERRORISM RISK INSURANCE PROGRAM
INITIAL NOTICE OF INSURED LOSS
Pursuant to 31 CFR 50.52, this notice is required to be submitted to Treasury when the incurred aggregate insured
losses (including reserves for “incurred but not reported”) for an insurer, or collectively for a group of affiliated
insurers, exceed an amount equal to 50 percent of the Program Year insurer deductible. One form is to be submitted
based on insured losses incurred for all Program Trigger Events1 that occurred to date in the Program Year. An
updated form may be requested, e.g., should there be subsequent Program Trigger Events in the same Program
Year. 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 #): ___________
List all affiliated insurers with premium subject to Terrorism Risk Insurance Act:
Name

NAIC # (or TIN if no NAIC #)

_______________________________

_______________________________

_______________________________

_______________________________

_______________________________

_______________________________

_______________________________

_______________________________

_______________________________

_______________________________

_______________________________

_______________________________

(insurers may add more lines as needed)
Program (calendar)Year: ________

ISO/PCS Catastrophe Code(s) _____ _____ _____ _____

Estimated aggregate insured losses from Program Trigger event(s): $____________________
Estimated insurer deductible for Program Year: $________________________
(see Certification of Loss Schedule A for guidance, even if Schedule A not submitted at this time)
Estimated Federal share of compensation: $_______________________
(90% of amount in excess of insurer deductible in 2006; 85% of amount in excess of insurer deductible in
2007)

1
Program Trigger Event means a certified act of terrorism that occurs after March 31, 2006, for which the
aggregate industry insured losses resulting from such act exceed $50 million with respect to such insured losses in
2006 or $100 million with respect to such insured losses in 2007.

OMB No. 1505-0200 Expiration: September 30, 2007
TRIP 01 (revised 07/2006)

Control Number:______________________
(Treasury use)
Point of contact for loss and compliance certifications and for payments of Federal share of compensation (in
the case of affiliated insurers, a single insurance entity among the affiliated group designated to act as the single
point of contact must be supplied):
Contact’s Name:
Contact’s Title:
Insurer Name:
Mailing Address:

Telephone Number(s):
Fax Number(s):
E-mail Address:
Optional Schedule A “Declaration of Direct Earned Premium and Insurer Deductible” attached? (Y or N)?
_____
Initial Notice of Insured Loss submitted by:
Name:

________________________________

Title:

________________________________

Signature:

________________________________

Date:

________________________________

Notice Under the Paperwork Reduction Act
We estimate it will take you about 60 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, Suite 2100, Washington, DC 20220. Do
not send completed form to this address. Submit forms according to instructions provided at www.treas.gov/trip.

OMB No. 1505-0200 Expiration: September 30, 2007
TRIP 01 (revised 07/2006)