Form 1 2016 TRIP Data Collection Form

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Overview

Affiliations
Premium (Juris.)
Number of Policies (Juris.)
Package Policies (US)
Standalone Terrorism (US)
Exposure Bases (Juris.)
Industry Code (NAICS or SIC)
Geographic (US)
Reinsurance (US)

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Sheet 1: Affiliations

A	B	C	D	E	F	G	H	I	J
2	NAIC Group Code	Insurer Group Name	NAIC Company Code	Insurance Company Name	Type of Insurer (Admitted (A), Domestic Surplus Lines (DSL), Alien Surplus Lines (ASL), Captive (C), Risk Retention Group (RRG), Residual Market Entity (RM), State Workers' Compensation Fund (WCF))	Total 2015 Net Admitted Assets	Total 2015 Policyholder Surplus	Total 2014 TRIP-Eligible DEP (all lines) (Cell E19 of Premium by Jurisdiction Worksheet, all Jurisdictions Combined)	Total 2015 TRIP-Eligible DEP (all lines) (Cell E16 of Premium by Jurisdiction Worksheet, all Jurisdictions Combined)
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22	TOTALS:
	General Instructions: Please provide the requested information for each company within an affiliated group of insurers (expanding the fields as necessary if your insurer group includes more companies for which space is provided that write TRIA-eligible lines insurance). The subsequent charts, however, seek information only on a consolidated insurer group basis. If not part of a group, please report information for your single company only. Premium information should be provided on a direct earned premium (DEP) basis. Financial data in all Worksheets should be provided in US Dollars, rounded whole numbers using a 1000 separator (,), and without any currency symbol (e.g., $). Refer to the Data Dictionary for further instructions. All information provided as part of this submission shall be certified by the responding insurer as a full and true statement of the information provided to the best of its knowledge, information, and belief.
			Notice Under the Paperwork Reduction Act
		We estimate that it will take you about 50 hours to complete this form (all worksheets combined), assuming you have information to provide in connection with all of the identified questions, and only about 25 hours if you have more limited information. 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 Federal Insurance Office, 1500 Pennsylvania Avenue, NW, Room 1410, Washington, DC 20220. Do not send completed forms to this address. Submit forms according to instructions provided at [http://www._____________]

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Sheet 2: Premium (Juris.)

A	B	C	D	E	F	G	H	I
2	TRIP-Eligible Line of Coverage	NAIC Line (Commercial Only)	Jurisdiction	Total 2015 TRIP-Eligible DEP (all policies)	Total 2015 TRIP-Eligible DEP when Terrorism Risk Coverage Not Purchased	Total 2015 TRIP-Eligible DEP when Terrorism Risk Coverage Provided for Disclosed $0 Charge	Total 2015 TRIP-Eligible DEP when Terrorism Risk Coverage Premium Charged	Total 2015 Disclosed Terrorism Risk Coverage DEP Charged
3	Fire	1
4	Allied Lines	2.1
5	Commercial Multiple Peril (non-liability portion)	5.1
6	Commercial Multiple Peril (liability portion)	5.2
7	Ocean Marine	8
8	Inland Marine	9
9	Workers' Compensation	16
10	Excess Workers' Compensation	16.0003
11	Other Liability	17
12	Umbrella and Excess (Commercial)	17.0020
13	Products Liability	18
14	Aircraft (all perils)	22
15	Boiler and Machinery	27
16	TOTALS
17	ALL DISCLOSED TERRORISM RISK PREMIUM COLLECTED IN ALL TRIA-ELIGIBLE LINES, 2003-2015
18	YEARS COVERED BY CELL I17 IF NOT 2003-2015
19	TOTAL 2014 TRIP-ELIGIBLE DEP (ALL LINES)
	General Instructions: See instructions in the Data Dictionary for this Worksheet.

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Sheet 3: Number of Policies (Juris.)

A	B	C	D	E	F	G	H
2	TRIP-Eligible Line of Coverage	NAIC Line (Commercial Only)	Jurisdiction	Total 2015 Number of Policies by line	Total 2015 Number of Policies by line when Terrorism Risk Coverage Not Purchased	Total 2015 Number of Policies by line when Terrorism Risk Coverage Provided for Disclosed $0 Charge	Total 2015 Number of Policies by line when Terrorism Risk Coverage Premium Charged
3	Fire	1
4	Allied Lines	2.1
5	Commercial Multiple Peril (non-liability portion)	5.1
6	Commercial Multiple Peril (liability portion)	5.2
7	Ocean Marine	8
8	Inland Marine	9
9	Workers' Compensation	16
10	Excess Workers' Compensation	16.0003
11	Other Liability	17
12	Umbrella and Excess (Commercial)	17.0020
13	Products Liability	18
14	Aircraft (all perils)	22
15	Boiler and Machinery	27
16	TOTAL
17	TOTAL NUMBER OF POLICIES CONTAINING TRIP-ELIGIBLE COVERAGE
	General Instructions: See instructions in the Data Dictionary for this Worksheet.

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Sheet 4: Package Policies (US)

A	B	C	D	E	F	G	H	I	J	K	L
2	Jurisdiction	Total 2015 Number of Package/Multi-line Policies containing at least one TRIP-Eligible Line	Total 2015 DEP associated with Package/Multi-line Policies containing at least one TRIP-Eligible Line	Total 2015 TRIP-Eligible DEP associated with Package/Multi-line Policies containing at least one TRIP-Eligible Line	Total 2015 Number of Package/Multi-line Policies containing at least one TRIP-Eligible Line, but where No Terrorism Risk Coverage was Purchased	Total 2015 TRIP-Eligible DEP associated with Package/Multi-line Policies containing at least one TRIP-Eligible Line, but where No Terrorism Risk Coverage was Purchased	Total 2015 Number of Package/Multi-line Policies containing at least one TRIP-Eligible Line where Terrorism Risk Coverage was provided for a Disclosed $0 Premium	Total 2015 TRIP-Eligible DEP associated with Package/Multi-line Policies containing at least one TRIP-Eligible Line where Terrorism Risk Coverage was provided for a Disclosed $0 Premium	Total 2015 Number of Package/Multi-line Policies containing at least one TRIP-Eligible Line where Terrorism Risk Coverage provided for a Disclosed non-$0 Premium	Total 2015 TRIP-Eligible DEP associated with Package/Multi-line Policies containing at least one TRIP-Eligible Line where Terrorism Risk Coverage provided for a Disclosed non-$0 Premium	Total 2015 Disclosed Terrorism Coverage DEP Charged under Package/Multi-line Policies containing at least one TRIP-Eligible Line
3	Alabama
4	Alaska
5	American Samoa
6	Arizona
7	Arkansas
8	California
9	Colorado
10	Connecticut
11	Delaware
12	District of Columbia
13	Florida
14	Georgia
15	Guam
16	Hawaii
17	Idaho
18	Illinois
19	Indiana
20	Iowa
21	Kansas
22	Kentucky
23	Louisiana
24	Maine
25	Maryland
26	Massachusetts
27	Michigan
28	Minnesota
29	Mississippi
30	Missouri
31	Montana
32	Nebraska
33	Nevada
34	New Hampshire
35	New Jersey
36	New Mexico
37	New York
38	North Carolina
39	North Dakota
40	Northern Marianas
41	Ohio
42	Oklahoma
43	Oregon
44	Pennsylvania
45	Puerto Rico
46	Rhode Island
47	South Carolina
48	South Dakota
49	Tennessee
50	Texas
51	Utah
52	Vermont
53	Virginia
54	Virgin Islands
55	Washington
56	West Virginia
57	Wisconsin
58	Wyoming
59	TOTALS
	General Instructions: See instructions in the Data Dictionary for this Worksheet.

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Sheet 5: Standalone Terrorism (US)

A	B	C
2	Element	Amount
3	2015 DEP for Standalone Terrorism Policies
4	Portion of 2015 DEP for TRIP Certified Terrorism Loss Coverage
5	Portion of 2015 DEP for Non-Certified Terrorism Loss Coverage
6	2015 Number of Standalone Terrorism Policies Issued
7	2015 Number of Standalone Terrorism Policies Covering TRIP Loss Issued
8	2015 Total Insured Values (TIVs) for Standalone Terrorism Policies Covering TRIP Loss (Property)
9	2015 Total Limits of Liability for Standalone Terrorism Policies Covering TRIP Loss (Liability)
	General Instructions: See instructions in the Data Dictionary for this Worksheet.

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Sheet 6: Exposure Bases (Juris.)

A	B	C	D	E	F	G	H	I
2	TRIP-Eligible Line of Coverage	NAIC Line (Commercial Only)	Jurisdiction	2015 Total Insured Values (TIVs) Subject to Terrorism Risk Coverage	2015 TIVs Not Subject to Terrorism Risk Coverage	Total 2015 Limits of Liability Subject to Terrorism Risk Coverage	Total 2015 Limits of Liability Not Subject to Terrorism Risk Coverage	Total 2015 Payroll Subject to Terrorism Risk Coverage
3	Fire	1
4	Allied Lines	2.1
5	Commercial Multiple Peril (non-liability portion)	5.1
6	Commercial Multiple Peril (liability portion)	5.2
7	Ocean Marine	8
8	Inland Marine	9
9	Workers' Compensation	16
10	Excess Workers' Compensation	16.0003
11	Other Liability	17
12	Umbrella and Excess (Commercial)	17.0020
13	Products Liability	18
14	Aircraft (all perils)	22
15	Boiler and Machinery	27
16	TOTALS
	General Instructions: See instructions in the Data Dictionary for this Worksheet.

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Sheet 7: Industry Code (NAICS or SIC)

A	B	C	D	E	F	G	H	I	J	K	L	M	N	O	P	Q	R	S	T
2	NAICS Code	NAICS Code Description Applicable to Policyholder	SIC Code	SIC Code Description	Jurisdiction	Total TRIP-Eligible DEP (all categories)		Total 2015 TRIP-Eligible DEP Property	Total 2015 TRIP-Eligible DEP Property When Terrorism Risk Coverage Not Purchased	Total 2015 TRIP-Eligible DEP Property When Terrorism Risk Coverage Purchased	Total 2015 Disclosed Terrorism Risk Coverage DEP Charged for Property		Total 2015 TRIP-Eligible DEP Other Commercial	Total 2015 TRIP-Eligible DEP Other Commercial When Terrorism Risk Coverage Not Purchased	Total 2015 TRIP-Eligible DEP Other Commercial When Terrorism Risk Coverage Purchased	Total 2015 Disclosed Terrorism Risk Coverage DEP Charged for Other Commercial		Total 2015 TRIP-Eligible DEP WC	Total 2015 Disclosed Terrorism Risk Coverage DEP Charged for WC
3	11	Agriculture, Forestry, Fishing & Hunting
4	21	Mining, quarrying and oil and gas extraction
5	22	Utilities
6	23	Construction
7	31-33	Manufacturing
8	42	Wholesale Trade
9	44-45	Retail Trade
10	48-49	Transportation & Warehousing
11	51	Information
12	52	Finance & Insurance
13	53	Real Estate and Rental and Leasing
14	54	Professional, Scientific & Technical Service
15	55	Management of Companies and Enterprises
16	56	Administrative & Support & Waste Management & Remediation Services
17	61	Educational Services
18	62	Health Care & Social Assistance
19	71	Arts, Entertainment & Recreation
20	72	Accommodation & Food Services
21	81	Other Services (except Public Administration)
22	92	Public Administration
23			01-09	Agriculture, Forestry & Fishing
24			10-14	Mining
25			15-17	Construction
26			20-39	Manufacturing
27			40-49	Transportation, Communications, Electric, Gas & Sanitary Services
28			50-51	Wholesale Trade
29			52-59	Retail Trade
30			60-67	Finance, Insurance & Real Estate
31			70-89	Services
32			91-99	Public Administration
33		TOTALS:
	General Instructions: Report direct earned premium information (DEP) as divided by the industry classification of your policyholders. Use NAICS Codes for purposes of allocation unless you still use SIC Codes; report in the appropriate fields for one or the other, but not both. Unlike other worksheets, this Worksheet does not seek information segregated by coverage subject to TRIA provided for a $0 disclosed premium charge. "Other Commercial" references liability coverages; see the Exposure Bases by Jurisdiction Worksheet to identify lines as divided between property and liability exposures. Refer to the data dictionary for further instructions.

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Sheet 8: Geographic (US)

A	B	C	D	E	F	G	H	I	J	K
2	Jurisdiction	Description	Total 2015 Payroll Subject to TRIP Coverage under Primary WC Coverage	Total 2015 Payroll Subject to TRIP Coverage under Excess WC Coverage	Total 2015 TIVs Subject to TRIP Property Coverage	Total 2015 TIVs Not Subject to TRIP Property Coverage	ZIP Code of Top 5 Largest Accumulated Exposure Locations by Payroll	Amount of Top 5 Largest Accumulated Exposure Locations by Payroll	ZIP Code of Top 5 Largest Accumulated Exposure Locations by TIVs subject to TRIP Property Coverage	Amount of Top 5 Largest Accumulated Exposure Locations by TIVs subject to TRIP Property Coverage
3	Atlanta. GA	All zip codes within the four counties of Fulton, DeKalb, Clayton, and Cobb.
4	Baltimore, MD	All zip codes in Baltimore City, all zip codes in Baltimore County excluding 21013, 21020,21023,21030, 21031, 21051, 21053, 21057, 21065, 21071, 21074, 21082, 21087, 21092, 21102, 21105, 21111, 21120, 21131, 21136, 21152, 21155, 21161; include the following zip codes from Anne Arundel County – 21060, 21061, 21062, 21076, 21077, 21090, 21098, 21122, 21123, 21144, 21225, 21226, 21240.
5	Boston. MA	All zip codes from Suffolk county; for Essex County only include zip codes 01901 thru 01908, 01910, 01945, 01960, 01961, 01970, 01971; for Norfolk County only include zip codes 02026, 02027, 02030, 02062, 02090, 02169, 02170, 02171, 02184 thru 02191, 02269, 02445, 02446, 02447, 02457, 02467, 02481, 02482, 02492, 02494; for Middlesex County only include zip codes 01701 thru 01705, 01760, 01770, 01776, 01778, 01801, 01803, 01805 thru 01808, 01813, 01815, 01866, 01867, 01880, 01888, 01890, 02138 thru 02145, 02148, 02149, 02153, 02155, 02156, 02176, 02180, 02212, 02238, 02239, 02420, 02421, 02451 thru 02456, 02458 thru 02462, 02464 thru 02468, 02471, 02472, 02474 thru 02479, 02493, 02495.
6	Charlotte, NC	All zip codes within the five counties of Mecklenburg, Gaston, York, Union and Cabarrus.
7	Chicago, IL	All zip codes within the four counties of Cook, DuPage, Lake, and Will.
8	Dallas/Ft. Worth, TX	All zip codes in the two counties of Dallas and Tarrant (Fort Worth).
9	Denver, CO	All zip codes in the counties of Denver, Adams, and Arapahoe.
10	Detroit, MI	All zip codes in the counties of Wayne, Oakland, and Macomb.
11	Houston, TX	All zip codes in Harris County.
12	Las Vegas, NV	All zip codes in Clark County.
13	Los Angeles, CA	All zip codes within the two counties of Los Angeles and Orange.
14	Miami, FL	All zip codes in Miami-Dade County.
15	Minneapolis/St. Paul, MN	All zip codes in the two counties of Hennepin and Ramsey.
16	New York, NY	All zip codes within the five counties of Kings (Brooklyn), Queens, New York (Manhattan), Bronx, and Richmond (Staten Island).
17	Newark, NJ	All zip codes for the cities of Newark (07101 thru 07108, 07112, 07114, 07175, 07182, 07184, 07188, 07189, 07191, 07192, 07193, 07194, 07195, 07198, 07199) and Elizabeth (07201, 07202, 07206, 07207, 07208).
18	Philadelphia, PA	All zip codes in Philadelphia County.
19	Phoenix, AZ	All zip codes in Maricopa County.
20	Pittsburgh, PA	All zip codes in Allegheny County.
21	Portland, OR	All zip codes in Multnomah County, OR and Clark County, WA.
22	Providence, RI	All zip codes in Providence County.
23	Riverside/San Bernardino, CA	All zip codes in the counties of Riverside and San Bernardino.
24	San Diego, CA	All zip codes in San Diego County
25	San Francisco, CA	All zip codes with the two counties of San Francisco and San Mateo.
26	Seattle, WA	All zip codes in King County.
27	St. Louis, MO	All zip codes in the two counties of St. Louis City and St. Louis.
28	Tampa/St. Petersburg, FL	All zip codes in the two counties of Hillsborough and Pinellas.
29	Washington, DC	All zip codes within Washington D.C. and all zip codes within the two counties of Arlington VA and Alexandria City VA.
30	TOTALS:
31
32	Jurisdiction	Description	Total 2015 Payroll Subject to TRIA Coverage under Primary WC Coverage	Total 2015 Payroll Subject to TRIA Coverage under Excess WC Coverage	Total 2015 TIVs Subject to TRIA Property Coverage	Total 2015 TIVs Not Subject to TRIA Property Coverage	ZIP Code of Top 5 Largest Accumulated Exposure Locations by Payroll	Amount of Top 5 Largest Accumulated Exposure Locations by Payroll	ZIP Code of Top 5 Largest Accumulated Exposure Locations by TIVs subject to TRIA Property Coverage	Amount of Top 5 Largest Accumulated Exposure Locations by TIVs subject to TRIA Property Coverage
33	All other Locations in the US	All areas in the US other than those specified in Cells C3-C29
34	All other Locations in the US
35	All other Locations in the US
36	All other Locations in the US
37	All other Locations in the US
38	GRAND TOTALS (Individual Jurisdictions plus all other locations in the US)
39
40	Largest Probable Maximum Loss (PML) at a Single Location
41	ZIP Code Associated with Largest PML
42				Payroll Coded by Employee Location (Y/N)	Payroll Coded by Headquarters Location (Y/N)	Payroll Coded based upon Other Method (Y/N)
43	Indicate in the adjoining cells if reported payroll is geocoded by separate locations where employees are located or if it is allocated by assignment to a single headquarters location, or otherwise assigned
	General Instructions: This template seeks exposure information by various metropolitan areas, then for the remainder of the US as a whole. Refer to the Data Dictionary for further instructions. The final questions (Lines 40 and 41) seek information concerning the insurer group or reporting company's largest Probable Maximum Loss at a single street level address location, assuming the detonation of a 5 ton truck bomb at that location.

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Sheet 9: Reinsurance (US)

A	B	C	D	E
2	Element	Amount	Yes/No	Description or Explanation (if any)
3	Size of TRIP 2015 Deductible (Cell I22 of Insurer Group Affiliations Chart x 20%)
4	Total 2015 Limits Any One Loss of Purchased Reinsurance Covering TRIA Loss
5	Total 2015 Aggregate Limits of Purchased Reinsurance Covering TRIA Loss
6	2015 Attachment Point of Purchased Treaty Reinsurance Covering TRIA Loss
7	2015 Co-Participation Share of Purchased Treaty Reinsurance Covering TRIA Loss
8	Total 2015 Limits Any One Loss of Purchased Reinsurance Covering Natural Catastrophic Loss
9	Total 2015 Aggregate Limits of Purchased Reinsurance Covering Natural Catastrophic Loss
10	2015 Attachment Point of Purchased Treaty Reinsurance Covering Natural Catastrophic Loss
11	2015 Co-Participation Share of Purchased Treaty Reinsurance Covering Natural Catastrophic Loss
12	Any reinsurance exclusions for TRIA Certified Foreign Acts of Terrorism?
13	Any reinsurance exclusions for TRIA Certified Domestic Acts of Terrorism?
14	Reinsurance for NBCR WC Exposures Resulting from Certified Acts of Terrorism?
15	If Yes, Total 2015 Limits of NBCR Reinsurance for Certified Acts of Terrorism involving WC Loss
16	If Yes, 2015 Attachment Point of NBCR Reinsurance for Certified Acts of Terrorism involving WC Loss
17	If Yes, 2015 Co-Participation Share (if any) of NBCR Reinsurance For Certified Acts of Terrorism involving WC Loss
18	Reinsurance for NBCR Property Loss Resulting from Certified Acts of Terrorism?
19	If Yes, Total 2015 Limits of NBCR Reinsurance for Certified Acts of Terrorism involving Property Loss
20	If Yes, 2015 Attachment Point of NBCR Reinsurance for Certified Acts of Terrorism involving Property Loss
21	If Yes, 2015 Co-Participation Share (if any) of NBCR Reinsurance for Certified Acts of Terrorism involving Property Loss
22	Reinsurance for NBCR Other Commercial Loss Resulting from Certified Acts of Terrorism?
23	If Yes, Total 2015 Limits of NBCR Reinsurance for Certified Acts of Terrorism involving Other Commercial Loss
24	If Yes, 2015 Attachment Point of NBCR Reinsurance for Certified Acts of Terrorism involving Other Commercial Loss
25	If Yes, 2015 Co-Participation Share (if any) of NBCR Reinsurance for Certified Acts of Terrorism involving Other Commercial Loss
26	Any other reinsurance exclusions specifically applicable to TRIP Certified Acts of Terrorism?
27
28	* Using the following defined terrorism event, calculate and report (1) the projected amount of loss the insurer group (or single company that is not part of a group) will sustain net within its TRIA deductible; (2) any private reinsurance recovery available to the group or company; (3) the amount of the group or company's claim under TRIP; and (4) the amount of the group or company's continuing co-pay obligation under TRIP. The scenario is a 5 ton truck bomb detonates at Rockefeller Center (45 Rockefeller Plaza, New York, NY 10111) on June 9, 2015 (a Tuesday) at 11:00 AM. Further assume that the loss does not involve any NBCR exposures, and that damage emanating from the blast site is characterized by the following:
29
30	Zone 1 (200 meters from site): Collapse and fire following, 100% property damage and 10% fire loss
31	Zone 2 (400 meters from site): Massive debris damage to surrounding properties (25% property damage, 2.5% fire loss)
32	Zone 3 (500 meters from site): Light debris damage to surrounding properties (10% property damage, 1% fire loss)
33	Injuries: 2,000 blue/white-collar worker deaths in total and 4,000 injuries in total
34
35	Loss Element	Amount
36	Loss to Group or Company within TRIP Deductible
37	Private Reinsurance Recovery
38	Claim under TRIP
39	Co-Pay Obligation
40	TOTAL (sum of C36-C39)
	General Instructions: See instructions in the Data Dictionary for this Worksheet.