TBD Terrorism Risk Insurance Program: Small Insurers

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Overview

Affiliations
Premium (Juris.)
Exposure Bases (Juris.)
Reinsurance (US)
PRA Notice

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Sheet 1: Affiliations

	B	C				G	H
3	NAIC Group Code	Insurer Group Name			3	Total 2015 Net Admitted Assets:
4					4	Total 2015 Policyholder Surplus:
					5	Total 2015 TRIP-Eligible DEP (all lines)
					6	Total 2016 TRIP-Eligible DEP (all lines)
	B	C	D
8	NAIC Company Code	Insurance Company Name	Type of Insurer
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

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Sheet 2: Premium (Juris.)

	Jurisdiction:
2
	B	C	D	E	F	G	H
5	TRIP-Eligible Line of Coverage	NAIC Line (Commercial Only)	Total 2016 TRIP-Eligible DEP (all policies)	Total 2016 TRIP-Eligible DEP when Terrorism Risk Coverage Not Purchased	Total 2016 TRIP-Eligible DEP when Terrorism Risk Coverage Provided for Disclosed $0 Charge	Total 2016 TRIP-Eligible DEP when Terrorism Risk Coverage Premium Charged	Total 2016 Disclosed Terrorism Risk Coverage DEP Charged
6	Fire	1	$-
7	Allied Lines	2.1	$-
8	Commercial Multiple Peril (non-liability portion)	5.1	$-
9	Commercial Multiple Peril (liability portion)	5.2	$-
10	Ocean Marine	8	$-
11	Inland Marine	9	$-
12	Workers' Compensation	16	$-
13	Excess Workers' Compensation	17.3	$-
14	Other Liability	17	$-
15	Products Liability	18	$-
16	Aircraft (all perils)	22	$-
17	Boiler and Machinery	27	$-
18	TOTALS		$-	$-	$-	$-	$-
20	All disclosed terrorism risk premium (DEP) collected in all TRIP-eligible lines, 2003-2016
21	Years provided in Cell C20 if not fully available for 2003-2016
22	Total 2015 TRIP-eligible DEP (all lines)

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Sheet 3: Exposure Bases (Juris.)

	Jurisdiction:
2
	B	C	D	E	F	G	H
5	TRIP-Eligible Line of Coverage	NAIC Line (Commercial Only)	Total 2016 Property Insurance Exposure Subject to Terrorism Risk Coverage	Total 2016 Property Insurance Exposure Not Subject to Terrorism Risk Coverage	Total 2016 Limits of Liability Subject to Terrorism Risk Coverage	Total 2016 Limits of Liability Not Subject to Terrorism Risk Coverage	Total 2016 Payroll Subject to Terrorism Risk Coverage
6	Fire	1
7	Allied Lines	2.1
8	Commercial Multiple Peril (non-liability portion)	5.1
9	Commercial Multiple Peril (liability portion)	5.2
10	Ocean Marine	8
11	Inland Marine	9
12	Workers' Compensation	16
13	Excess Workers' Compensation	17.3
14	Other Liability	17
15	Products Liability	18
16	Aircraft (all perils)	22
17	Boiler and Machinery	27
18	TOTALS		$-	$-	$-	$-	$-

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Sheet 4: Reinsurance (US)

	B	C	D
2	Element	Response	Description or Explanation (if any)
3	Size of TRIP 2016 Deductible (Cell H5 of Insurer Group Affiliations Chart x 20%)
4	Total 2016 Limits Any One Loss of Purchased Reinsurance Covering TRIP Loss
5	Total 2016 Aggregate Limits of Purchased Reinsurance Covering TRIP Loss
6	2016 Attachment Point of Purchased Treaty Reinsurance Covering TRIP Loss
7	2016 Co-Participation Share of Purchased Treaty Reinsurance Covering TRIP Loss
8	Total 2016 Limits Any One Loss of Purchased Reinsurance Covering Natural Catastrophic Loss
9	Total 2016 Aggregate Limits of Purchased Reinsurance Covering Natural Catastrophic Loss
10	2016 Attachment Point of Purchased Treaty Reinsurance Covering Natural Catastrophic Loss
11	2016 Co-Participation Share of Purchased Treaty Reinsurance Covering Natural Catastrophic Loss
12	Any reinsurance exclusions for TRIP Certified Foreign Acts of Terrorism?
13	Any reinsurance exclusions for TRIP Certified Domestic Acts of Terrorism?
14	Reinsurance for NBCR WC Exposures Resulting from Certified Acts of Terrorism?
15	If Yes, Total 2016 Limits of NBCR Reinsurance for Certified Acts of Terrorism involving WC Loss
16	If Yes, 2016 Attachment Point of NBCR Reinsurance for Certified Acts of Terrorism involving WC Loss
17	If Yes, 2016 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 2016 Limits of NBCR Reinsurance for Certified Acts of Terrorism involving Property Loss
20	If Yes, 2016 Attachment Point of NBCR Reinsurance for Certified Acts of Terrorism involving Property Loss
21	If Yes, 2016 Co-Participation Share (if any) of NBCR Reinsurance for Certified Acts of Terrorism involving Property Loss
22	Reinsurance for NBCR Liability Loss Resulting from Certified Acts of Terrorism?
23	If Yes, Total 2016 Limits of NBCR Reinsurance for Certified Acts of Terrorism involving Liability Loss
24	If Yes, 2016 Attachment Point of NBCR Reinsurance for Certified Acts of Terrorism involving Liability Loss
25	If Yes, 2016 Co-Participation Share (if any) of NBCR Reinsurance for Certified Acts of Terrorism involving Liability Loss
26	Any other reinsurance exclusions specifically applicable to TRIP Certified Acts of Terrorism?

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Sheet 5: PRA Notice

Notice under the Paperwork Reduction Act

We estimate it will take you about 25 hours to complete this form. However, you are not required to provide the 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, Department of the Treasury, 1500 Pennsylvania Avenue NW, Room 1410 MT, Washington, DC 20220. Do not send completed forms to this address. Submit forms according to instructions provided at www.treas.gov/trip.