Form TRIP 03 TRIP 03 Notice of Proposed Settlement ? Request for Approval

Reference No. _____________

(Treasury use)

TERRORISM RISK INSURANCE PROGRAM

SUBMIT PROPOSED SETTLEMENT OF THIRD PARTY CLAIM

Notice of Proposed Settlement – Request for Approval

In compliance with 31 C.F.R., Part 50, Subpart I (§§50.82-83), Terrorism Risk Insurance Program; Litigation Management Rule, settlements of certain causes of action for property damage, personal injury, or death arising out of or related to certified acts of terrorism require Treasury's advance approval of settlements as a condition precedent for inclusion in an insurer's aggregate insured losses in its request for Federal share of compensation under the Program. You should refer to the online reference of 31 C.F.R §§50.82-83 for the advance approval requirements.

Please use this form to submit a proposed settlement for review and processing. Please attach continuation sheets, as needed. After it has been determined that all required information is present, it will be forwarded to Treasury for consideration. A separate completed form is required for each proposed settlement. If a field does not apply to the settlement, in the space provided enter 0 (zero) for amount fields, or N/A for other fields, to signify that the entry is not applicable.

If you have any questions, please contact the TRIP Claims Facility at 1-800-543-4292 or [email protected].

Insurer or Insurer Group Name: ________________________________

NAIC Insurer (or Group) Number (or TIN if no NAIC #): ___________

Program (calendar) Year: ________

Authorized Contact for the claim (if other than point of contact for Certifications):

Contact’s Name:

Contact’s Title:

Organization/Company:

Mailing Address:

Telephone Number(s):

E-mail Address:

Third Party Claim Information:

Claim Number:

ISO/PCS Cat Code:

Insured Name:

Policyholder Name:

Line of Business:

Date of Loss:

Third Party:

Are there any other Property and Casualty insurers involved with this loss? (Y/N) ______

If Yes, please identify:

Supporting Details

Please provide a brief description of the facts and circumstances, the types and layers of coverage, and include any appropriate amounts for the:

Underlying Claim Against the Insured:

Insured’s Liability for the Loss:

Amounts Claimed Against the Insurer:

Operative Policy Terms:

Defenses to Coverages:

Insurer’s Estimate of All Damages

Sustained:

Itemized Statement of Damages

Please provide an itemization of all damages claimed by the third party, by category:

Category Amount Claimed (of the proposed settlement)

Actual: $

Economic Loss: $

Non-Economic Loss: $

Punitive Damages: $

Other: $

(Describe Other):

Total: $

Proposed Settlement Details

Proposed Settlement Amount: $

Net Amount to be received by the Third Party (if known) net of

fees and expenses of attorneys, experts and other professionals: $

If the settlement is approved, enter the claim amount that would

be submitted on the Bordereau: $

Related Questions		Answer	If Yes, Please Specify Amount
1.	Is any portion of the proposed settlement amount that is attributable to an insured loss or losses involving personal injury or death in the aggregate $2 million or more per third-party claimant, regardless of the number of causes of action or insured losses being settled?	____ Yes ____ No ____ Uncertain	$
2.	Is any portion of the proposed settlement amount that is attributable to an insured loss or losses involving property damage (including loss of use) in the aggregate $10 million or more per third-party claimant, regardless of the number of causes of action or insured losses being settled?	____ Yes ____ No ____ Uncertain	$
3a.	Is any amount of the proposed settlement attributable to punitive or exemplary damages (whether or not specifically so described as such damage)?	____ Yes ____ No ____ Uncertain	$
3b.	Did the third-party assert a claim for punitive or exemplary damages in any filed or threatened legal action against the insurer?	____ Yes ____ No ____ Uncertain
3c.	If Yes to 3a or 3b, describe the nature of the claim or conduct the third-party alleged entitled it to punitive or exemplary damages.
4a.	Was any amount received by the third-party from the United States pursuant to any other Federal program for compensation of insured losses related to an act of terrorism? (see 31 C.F.R., Part 50, Subpart F (§50.51(b)(2)(i))	____ Yes ____ No ____ Uncertain	$
4b.	If Yes to 4a, which Federal agency?
4c.	If Yes to 4a, does the proposed settlement already factor or offset amounts received from the United States pursuant to any other Federal program?	____ Yes ____ No ____ Uncertain	$
5.	Will any part of the proposed settlement amount compensate for any items such as fees and expenses of attorneys, experts and other professionals for their services and expenses related to the insured loss and/or settlement?	____ Yes ____ No ____ Uncertain	$
6.	Was the proposed settlement negotiated by counsel?	____ Yes ____ No ____ Uncertain
7a.	Has the proposed settlement amount been approved by any Federal court?	____ Yes ____ No ____ Uncertain
7b.	Is the proposed settlement amount subject to approval by any Federal court?	____ Yes ____ No ____ Uncertain
7c.	If Yes to 7b, is such approval likely?	____ Yes ____ No ____ Uncertain
8a.	Is this proposed settlement part of a class action?	____ Yes ____ No ____ Uncertain
8b.	If Yes to 8a, please specify the class action case number.

Supporting Materials

A statement from the insurer or its attorney in support of the proposed settlement has been attached (Y/N) __________

The Proposed terms of the written settlement agreement, including release language and subrogation terms, has been attached (Y/N) __________

Other information that is related to the insured loss that you would like Treasury to consider in evaluating the proposed settlement amount has been attached (Y/N) __________

Executive Officer Certification

I hereby certify that the statements, data, calculations and supporting documentation submitted with this request for approval of the proposed claim settlement 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.

1. The proposed settlement compensates for a bona fide loss that is an insured loss under the terms and conditions of the underlying commercial property and casualty insurance policy.

2. Attorneys' fees and expenses in connection with the settlement are reasonable and appropriate, in whole, or in part and have not caused the insured losses under the underlying commercial property an casualty insurance policy to be overstated.

3. All necessary steps consistent with appropriate business practices have been taken to reasonably, properly, and carefully investigate and ascertain the amount of the loss.

4. The settlement is for a third-party's loss the liability for which is an insured loss under the terms and conditions of the underlying commercial property and casualty insurance policy.

Executive Officer Certification – Security Verification

Name: ________________________________

Title: ________________________________

Signature: ________________________________

Date: ________________________________

Notice Under the Paperwork Reduction Act

We estimate it will take you about 4 hours 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 forms to this address. Submit forms according to instructions provided at http://www.treas.gov/trip.

OMB No. 1505-0196 Expiration: June 30, 2016

TRIP 03