Initial 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: $_______________________

(85% of amount in excess of insurer deductible)

_________________________________

Program Trigger Event means a certified act of terrorism for which the aggregate industry insured losses resulting from such act exceed $100 million with respect to such insured losses.

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: February 28, 2017

TRIP 01