Form FMS 285-A FMS 285-A Schedule of Excess Risks

SCHEDULE OF EXCESS RISKS

DEPARTMENT OF THE TREASURY
BUREAU OF THE FISCAL SERVICE
HYATTSVILLE, MD 20782

Company Name

Contact Person

Location of Company

Contact Person Title

NAIC Company Code

Contact Person Telephone No.

Quarter Ended

Contact Person E-Mail

OMB No. 1530-XXXX

Treasury Underwriting Limitation
Report each risk written in excess of the underwriting limitation established by the Treasury. (This applies to casualty and other lines of business as well as surety risks whether or not the United States is obligee.) In protecting excess risks, the underwriting limitation in force on the date of the execution of
the risk, as shown in Treasury Circular 570, will govern absolutely.
Coinsurance Or Reinsurance
Amounts of Risks

Net Retention

Date Of
Coinsurance
Or
Reinsurance

T

Date

Penal Sum (If Bond) Maximum Liability (If
Or Face Amount (If Less Than Penal Sum
Policy)
Or Face Amount)

Retention For
Treasury
Purposes

Remarks

D

R
AF

Number

Principal (If Surety) Or
Class (If Other Lines)

Obligee (If Fidelity Or
Surety) Or Insured (If
Other Lines)

Amount of
Market Value Of
Unauthorized
Admissible Assets
Amount of Treasury
Pledged (Attach Copy
Coinsurance
Name Of Coinsuring Authorized Coinsurance (Denote With*) Or
Of Trust, Joint
(Denote With*) Or
Control Or Indemnity
Or Reinsuring
Unauthorized
Company
Authorized Reinsurance
Reinsurance
Agreement

AFFIDAVIT
State of ___________________________________
County of__________________________________
_____________________________________, President, and __________________________________, Secretary of the_________________________________ of ____________________________________, being duly sworn, depose and say, and each for himself says, that they are the abovedescribed officers of the said company, that the foregoing schedule (with the accompanying exhibits) contains a full, true, and correct statement of all recognizances, stipulations, bonds, undertakings, or other risks, whereon the liabilities are in excess of its Treasury underwriting limitation, executed by the said
company and its agents on behalf of any individual, firm, association, or corporation, during the quarter ended___________________, 20____; and, further, that the statements and declarations contained herein are correct and true in every particular.
Subscribed and sworn to before me this_______________________day of___________________, 20___
_____________________________________________________
Notary Public
_____________________________________________________
President
_____________________________________________________
Secretary
FMS FORM 1-99
285-A EDITION OF (12-95)
IS OBSOLETE

NOTE TO PRESIDENT AND SECRETARY: If any amount in the "Retention for Treasury Purposes" column exceeds
the "Treaury Underwriting Limitation", it is probable that applicable Treasury regulations have been violated (see Treasury
Circular 297, sections 223.10, .11 and .13). If so, immediate remedial measures are required to comply with the regulations.

DEPARTMENT OF THE TREASURY
BUREAU OF THE FISCAL SERVICE
HYATTSVILLE, MD 20782

Obligee (If Fidelity Or
Surety) Or Insured (If
Other Lines)

Penal Sum (If Bond) Maximum Liability (If
Or Face Amount (If Less Than Penal Sum
Or Face Amount)
Policy)

Coinsurance Or Reinsurance

Net Retention

Date Of
Coinsurance
Or
Reinsurance

Amount of
Market Value Of
Unauthorized
Admissible Assets
Amount of Treasury
Pledged (Attach Copy
Coinsurance
Of Trust, Joint
Name Of Coinsuring Authorized Coinsurance (Denote With*) Or
(Denote With*) Or
Control Or Indemnity
Unauthorized
Or Reinsuring
Agreement
Authorized Reinsurance
Reinsurance
Company

R
AF

T

Date

Amounts of Risks

D

Number

Principal (If Surety) Or
Class (If Other Lines)

FMS FORM 1-99
285-A EDITION OF (12-95)
IS OBSOLETE

OMB No. 1530-XXXX

SCHEDULE OF EXCESS RISKS

Retention For
Treasury
Purposes

Remarks

DEPARTMENT OF THE TREASURY
BUREAU OF THE FISCAL SERVICE
HYATTSVILLE, MD 20782

Obligee (If Fidelity Or
Surety) Or Insured (If
Other Lines)

Penal Sum (If Bond) Maximum Liability (If
Or Face Amount (If Less Than Penal Sum
Or Face Amount)
Policy)

Coinsurance Or Reinsurance

Net Retention

Date Of
Coinsurance
Or
Reinsurance

Amount of
Market Value Of
Unauthorized
Admissible Assets
Amount of Treasury
Pledged (Attach Copy
Coinsurance
Of Trust, Joint
Name Of Coinsuring Authorized Coinsurance (Denote With*) Or
(Denote With*) Or
Control Or Indemnity
Unauthorized
Or Reinsuring
Agreement
Authorized Reinsurance
Reinsurance
Company

R
AF

T

Date

Amounts of Risks

D

Number

Principal (If Surety) Or
Class (If Other Lines)

FMS FORM 1-99
285-A EDITION OF (12-95)
IS OBSOLETE

OMB No. 1530-XXXX

SCHEDULE OF EXCESS RISKS

Retention For
Treasury
Purposes

Remarks

DEPARTMENT OF THE TREASURY
BUREAU OF THE FISCAL SERVICE
HYATTSVILLE, MD 20782

Obligee (If Fidelity Or
Surety) Or Insured (If
Other Lines)

Penal Sum (If Bond) Maximum Liability (If
Or Face Amount (If Less Than Penal Sum
Or Face Amount)
Policy)

Coinsurance Or Reinsurance

Net Retention

Date Of
Coinsurance
Or
Reinsurance

Amount of
Market Value Of
Unauthorized
Admissible Assets
Amount of Treasury
Pledged (Attach Copy
Coinsurance
Of Trust, Joint
Name Of Coinsuring Authorized Coinsurance (Denote With*) Or
(Denote With*) Or
Control Or Indemnity
Unauthorized
Or Reinsuring
Agreement
Authorized Reinsurance
Reinsurance
Company

R
AF

T

Date

Amounts of Risks

D

Number

Principal (If Surety) Or
Class (If Other Lines)

FMS FORM 1-99
285-A EDITION OF (12-95)
IS OBSOLETE

OMB No. 1530-XXXX

SCHEDULE OF EXCESS RISKS

Retention For
Treasury
Purposes

Remarks

DEPARTMENT OF THE TREASURY
BUREAU OF THE FISCAL SERVICE
HYATTSVILLE, MD 20782

SPECIFIC INSTRUCTIONS

Column A "Number" - Insert number of bond or policy.
Column B "Date" - Insert date bond or policy was written.
Column C "Principal (if surety) or Class (if other lines)" - Insert name of principal (if bond) or class (if other line).
Column D "Obligee (if fidelity or surety) or Insured (if other lines)" - Insert name of obligee if fidelity or surety or
name of insured if other line.
Column E "Penal Sum (if bond) or Face Amount (if policy)" - Insert penal amount of bond or face amount of
insurance policy.
Column F "Maximum Liability (if less than penal sum or face amount)" - Insert maximum liability if less than penal
sum of bond or face amount of insurance policy. This column is used only in cases where policies cover more than
one risk, i.e., casualty policies covering more than one location, or where bonds, such as fiduciary bonds are given
for more than the value of the assets in an estate. (See Section 223.13 of Treasury Circular 297 - 31 CFR 223.13.)

AF
T

Column G "Net Retention" - Insert net retention (amount of risk retained by company after coinsurance,
reinsurance or admissible collateral is obtained).
Column H "Date of Coinsurance or Reinsurance" - Insert date of coinsurance or reinsurance.

Column I "Name of Coinsuring or Reinsuring Company" - Insert names of coinsuring or reinsuring companies.
Column J "Amount of Treasury Authorized Coinsurance or Authorized Reinsurance" - Insert amount of
coinsurance or reinsurance ceded to companies recognized by Treasury for reinsurance purposes opposite their
names. See lists of reinsurers which accompanied Treasury's last Annual Letter to Executive Officers of Surety
Companies Reporting to the Treasury for names of companies recognized by the Treasury for reinsurance purposes.
Indicate coinsurance by single asterisk.

R

Column K "Amount of Unauthorized Coinsurance or Authorized Reinsurance" - Insert amount of coinsurance or
reinsurance ceded to companies not recognized by the Treasury opposite their names.

D

Column L "Market Value of Admissible Assets Pledged (attach copy of trust, joint control or indemnity agreement)"
- Insert market value of any admissible assets held to secure each excess risk. If protection of the excess liability is
being achieved by pledged assets, assets held in trust, assets held under collateral agreement of indemnity or joint
control, insert market value of such assets. In order to qualify, pledged assets should be of the type that would be
admissible if owned directly by the reporting company. See Sections 223.10 - .11 of Treasury Circular 297 for
applicable regulations (31 CFR 223.10 - .11).
Column M "Retention for Treasury Purposes" - Insert Retention for Treasury purposes. This amount should equal
the company's net retention plus cessions to unauthorized coinsurers or reinsurers, less the market value of any
admissible assets held to secure the risk and must not exceed the reporting company's Treasury underwriting
limitation.
Column N "Remarks" - Insert any remarks to clarify. If the risk being reported is a surety bond naming the United
States or one of its agencies or instrumentalties as obligee, a copy of the appropriate reinsurance agreement should
be attached and a remark written in column (17) "Reinsurance Agreement Attached." Reinsurance Agreements on
Federal bonds should be executed on Standard Forms (SF) 273, 274, or 275. Use SF-273 for Miller Act
performance bonds; SF 274 for Miller Act payment bonds; and SF 275 for other Federal bonds. The previous
Treasury form nos. FMS 6317, FMS 6318, and FMS 6319 may continue to be used. (See paragraph) 223.11 (b) (1)
of Treasury Circular 297 - 31 CFR 223.11 (b) (1).)

OMB No. 1530-XXXX

SPECIFIC INSTRUCTIONS

D

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AF
T

Note: If no risks are written in excess of the underwriting limitation, indicate such by inserting the word
"NONE" on the form.

GENERAL INSTRUCTIONS

DEPARTMENT OF THE TREASURY
BUREAU OF THE FISCAL SERVICE
HYATTSVILLE, MD 20782

OMB No. 1530-XXXX

A. REPORT EACH RISK SEPARATELY WITH THE EXCEPTION OF TREATY REINSURANCE AND PAYMENT
TONDS AS MENTIONED BELOW.
B. SURETY RISKS: All surety risks should be reported in detail.
C. CONTRACT BONDS: A separate entry on the form may be used to report the performance bond and the payment bond
on a single contract. However, in cases where the performance bond and the payment bond for a single contract are reinsured
in the same manner it is permissible to report the details of the performance bond and a statement indicating "payment bond
also protected in the same manner".
D. FACULTATIVE REINSURANCE: All excess risks protected by facultative reinsurance should be reported in detail. Use
a separate line on the form for each risk.

AF
T

E. RISKS COVERED BY TREATIES: In property - liability lines of business such as automobile and public liability, where
the excess risks may be quite numerous and where reinsurance of such risks is covered automatically under reinsurance
agreements or treaties, it is not necessary to report risks in detail. A condensed summary showing the names of the reinsuring
companies and the limits accepted by them on the various classes of business should be noted on the schedule. Treaty
reinsurance should be reported in dollar amounts rather than percentages, with dollar amounts inserted for the largest risk
written under the treaty. Each treaty should be reported separately on the form. If it is necessary to submit the details of a
particular treaty in successive quarterly reports reproduced summaries may be submitted attached to form 285-A.
F. BLANK FORMS: FMS 285-A. A supply of blank forms is available from the Treasury. Blank reinsurance agreement
forms are also availabe, i.e., Standard Forms (SF) 273, 274, 275. A set of two FMS 285-A forms is mailed to each reporting
company each quarter.
G. SPECIMEN FORMS: A specimen form, FMS 285-A properly filled out, is available from the Treasury upon request.
H. TREASURY ADDRESS: Requests for blank forms, specimen forms, and questions should be addressed to:

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U.S. Treasury Department
Financial Management Service
Surety Bond Branch
3700 East/West Highway, Room 6F04
Hyattsville, MD 20782
Telephone: (202) 874-6850

I. REPORTING DATES: The completed Schedule of Excess Risks (form FMS 285-A) together with the reporting company's
quarterly financial statement should be submitted to the same address, within 45 days after the close of each quarter.
Notice Under the Paperwork Reduction Act:
We estimate it will take you about 20 minutes to complete this form. However, you are not required to provide information
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