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 provided a clear and conspicuous disclosure to the policyholder, of any policy issued after December 26, 2007, at the time of offer, purchase and renewal thereafter, of the existence of the $100 billion cap on payments for insured losses under section 103(e)(2) of TRIA, for each underlying insured loss that is included in the amount of the insurer’s aggregate insured losses.

6. 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

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: February 28, 2017

TRIP 02B