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):

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 (85% of subtotal Excess of Deductible)	$ ________________________
Less Excess Insurer Recoveries (see 21below)	$ _________________________
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):

Total Reinsurance Recoveries from Program Trigger Events	$ ________________________
Less Recoveries Repaid or to be Repaid to Reinsurers	$ ________________________
Subtotal Net Reinsurance Recoveries	$ ________________________
Plus Gross Federal Share (line 9)	$ ________________________
Subtotal Total Insurer Recoveries	$ ________________________
Less Adjusted Insured Losses Paid (line 6) Total Excess Insurer Recoveries (if less than zero, enter zero above)	$ ________________________ $ ________________________

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: December 31, 2013

TRIP 02