Schedule B

Control Number_____________
(Treasury use)

Schedule B
TERRORISM RISK INSURANCE PROGRAM
CERTIFICATION OF COMPLIANCE WITH SECTION 103(b)
OF TERRORISM RISK INSURANCE ACT (TRIA)
Insurer or Insurer Group Name: _________________________
NAIC Insurer (or Group) Number or TIN (if no NAIC #): ______
If insurer is residual market mechanism allocating losses, enter loss allocation date: ________
Program (calendar) Year: ______
I hereby certify that to the best of my information, knowledge and belief:
A. For each insurer with underlying losses included with this Certification of Loss:
1. The insurer has either (a) paid all underlying claims comprising the insured losses listed
in the bordereau provided pursuant to 31 CFR 50.53(b)(1), or (b) will pay such
underlying claims upon receipt of an advance payment of the Federal share of
compensation as soon as possible, consistent with the insurer’s normal business practices,
but not longer than five business days after receipt of the Federal share of compensation;
2. The underlying claims for insured losses were filed by persons who suffered an insured
loss, or by persons acting on behalf of such persons;
3. The underlying claims for insured losses were processed in accordance with appropriate
business practices and the procedures specified in 31 CFR Part 50 Subpart F;
4. The insurer has provided clear and conspicuous disclosure to the policyholder of the
premium charged for insured losses covered by the Program and the Federal share of
compensation for insured losses under the Program by complying with the disclosure
requirements of 31 CFR 50.10 through 50.19 for each underlying insured loss that is
included in the amount of the insurer’s aggregate insured losses;
5. The insurer has made available, in all of its commercial property and casualty insurance
policies, coverage for insured losses that does not differ materially from the terms,
amounts, and other coverage limitations applicable to losses arising from events other
than acts of terrorism by complying with the mandatory availability requirements of 31
CFR 50.20 through 50.24; and
B. Disbursements of the Federal share of compensation to affiliated insurers, if applicable, will be
accomplished in accordance with 31 CFR Part 50 Subpart F.
Any false or fraudulent statements or claims may subject the insurer and signatory to criminal, civil, or
administrative penalties.
______________________________
Name

_____________________________ ____________________
Officer Title
Date

_____________________________
Signature
OMB No. 1505-0200 Expiration: September 30, 2007
TRIP 02B (04/2006)

Control Number_____________
(Treasury use)
Notice Under the Paperwork Reduction Act
We estimate it will take you about 15 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.

OMB No. 1505-0200 Expiration: September 30, 2007
TRIP 02B (04/2006)