Revision to OMB Approved Schedule C - No Burden Change

DRAFT 9/2008

SCHEDULE C - Bordereau Proposed Revision

TERRORISM RISK INSURANCE PROGRAM

INSURER or INSURER GROUP NAME:

NAIC INSURER (or GROUP) NUMBER (or TIN if no NAIC #):

PROGRAM YEAR:

DATA AS OF:

Field #:

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15a.

15b.

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

CAT CODE

LOB CODE

LOC OF LOSS/

DOL - Date of Loss

INSURER NUMBER

INSURER NAME

CLAIM #

INSURED NAME

INSURED TIN

EFF DT

EXP DT

WC

NUMBER

PRIOR

CURRENT LOSS

CURRENT LOSS

TOTAL

PUNITIVE

ALAE PAID

SALV

SUBRO

SALV/SUBRO

REINS

DUPLICATE FEDERAL

AMT ONE OF

SOURCE ONE OF

AMT TWO OF

SOURCE TWO OF

THIRD PARTY

CLAIM

RESERVES

Date of

Settlement

Total

STATE CD

XX/XX/XXXX

XX/XX/XXXX

XX/XX/XXXX

INDICATOR

OF WC

CUMULATIVE

PAYMENT INFORMATION

PAYMENT INFORMATION

CUMULATIVE

DMG PD

RECOVRD

RECOVRD

RECOVRD

RECVRBLE?

COMP

DUPLI FED COMP

FED COMP

DUPLI FED COMP

FED COMP

INDICATOR

STATUS

Latest

Date

Unprorated

MO, MI or II

CLAIMANTS

LOSS PAYMENTS

a. LOSS PAID AMOUNT

b. LOSS TO BE PAID AMOUNT

LOSS PAYMENTS

Y or N

Y, P or N

Y or N

O,C or R

Payment

Loss Amount

Totals:

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NA

NA

0.00

NA

0.00

NA

NA

NA

0.00

NA

NA

0.00

Instruction to add more lines

Please insert new rows before the Totals row. The Totals row has formulae in the fields that need to be totaled.

As this spreadsheet has been constructed with formulae for data fields that need to be totaled, please insert any additional data records (rows) before (above) the “Totals” row.