| 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 |
| Jurisdiction: | ||||||||||||||||
| 2 | ||||||||||||||||
| B | C | D | E | F | G | H | I | J | K | L | ||||||
| Direct Earned Premium | Number of Policies | |||||||||||||||
| 6 | 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 | Total 2016 Number of Policies by Line (Terrorism Risk Coverage Not Purchased) | Total 2016 Number of Policies by Line (Terrorism Risk Coverage Provided for Disclosed $0 Charge) | Total 2016 Number of Policies by Line (Terrorism Risk Coverage Premium Charged) | Total 2016 Number of Policies by Line | |||||
| 7 | Marine, Aviation, and Transport | 8, 9, 22 | $- | 0 | ||||||||||||
| 8 | Workers' Compensation or Excess Workers' Compensation | 16, 17.3 | $- | 0 | ||||||||||||
| 9 | Miscellaneous Financial Loss | 1, 9, 17, 18 | $- | 0 | ||||||||||||
| 10 | Fire and Other Damage to Property | 1, 2.1, 5.1, 9, 27 | $- | 0 | ||||||||||||
| 11 | General Liability | 5.2, 17, 18 | $- | 0 | ||||||||||||
| 12 | TOTALS | $- | $- | $- | $- | $- | 0 | 0 | 0 | 0 | ||||||
| 14 | All disclosed terrorism risk premium (DEP) collected in all TRIP-eligible lines, 2003-2016 | |||||||||||||||
| 15 | Years provided in Cell C14 if not fully available for 2003-2016 | |||||||||||||||
| 16 | Total 2015 TRIP-eligible DEP (all lines) | |||||||||||||||
| 17 | Total 2016 Number of Policies Containing TRIP-Eligible Coverage | |||||||||||||||
| B | C | |
| 2 | Element | Amount |
| 3 | 2016 DEP for Standalone Terrorism Policies | |
| 4 | 2016 DEP for TRIP Certified Terrorism Loss Coverage | |
| 5 | 2016 DEP for Non-Certified Terrorism Loss Coverage | |
| 6 | 2016 Number of Standalone Terrorism Policies Issued | |
| 7 | 2016 Number of Standalone Terrorism Policies Covering TRIP Loss Issued | |
| 8 | 2016 Total Property Insurance Exposure for Standalone Terrorism Policies Covering TRIP Loss | |
| 9 | 2016 Total Liability Policy Limits for Standalone Terrorism Policies Covering TRIP Loss |
| 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 | Marine, Aviation, and Transport | 8, 9, 22 | |||||||||
| 7 | Workers Compensation or Excess Workers' Compensation | 16, 17.3 | |||||||||
| 8 | Miscellaneous Financial Loss | 1, 9, 17, 18 | |||||||||
| 9 | Fire and Other Damage to Property | 1, 2.1, 5.1, 9, 27 | |||||||||
| 10 | General Liability | 5.2, 17, 18 | |||||||||
| 11 | TOTALS | $- | $- | $- | $- | $- | |||||
| B | C | D | E | F | G | H | I | J | K | L | M | N | O | |
| Property | Liability | Workers' Compensation | All Categories | |||||||||||
| 3 | Code | Description | Total 2016 Disclosed Terrorism Risk Coverage DEP Charged | Total 2016 TRIP-Eligible DEP When Terrorism Risk Coverage Not Purchased | Total 2016 TRIP-Eligible DEP When Terrorism Risk Coverage Purchased | Total 2016 TRIP-Eligible DEP | Total 2016 Disclosed Terrorism Risk Coverage DEP Charged | Total 2016 TRIP-Eligible DEP When Terrorism Risk Coverage Not Purchased | Total 2016 TRIP-Eligible DEP When Terrorism Risk Coverage Purchased | Total 2016 TRIP-Eligible DEP | Total 2016 Disclosed Terrorism Risk Coverage DEP Charged | Total 2016 TRIP-Eligible DEP | Total 2016 TRIP-Eligible DEP | |
| 4 | NAICS Code | 11 | Agriculture, Forestry, Fishing & Hunting | $- | $- | $- | ||||||||
| 5 | 21 | Mining, Quarrying, and Oil & Gas Extraction | $- | $- | $- | |||||||||
| 6 | 22 | Utilities | $- | $- | $- | |||||||||
| 7 | 23 | Construction | $- | $- | $- | |||||||||
| 8 | 31-33 | Manufacturing | $- | $- | $- | |||||||||
| 9 | 42 | Wholesale Trade | $- | $- | $- | |||||||||
| 10 | 44-45 | Retail Trade | $- | $- | $- | |||||||||
| 11 | 48-49 | Transportation & Warehousing | $- | $- | $- | |||||||||
| 12 | 51 | Information | $- | $- | $- | |||||||||
| 13 | 52 | Finance & Insurance | $- | $- | $- | |||||||||
| 14 | 53 | Real Estate and Rental and Leasing | $- | $- | $- | |||||||||
| 15 | 54 | Professional, Scientific & Technical Service | $- | $- | $- | |||||||||
| 16 | 55 | Management of Companies and Enterprises | $- | $- | $- | |||||||||
| 17 | 56 | Administrative & Support & Waste Management & Remediation Services | $- | $- | $- | |||||||||
| 18 | 61 | Educational Services | $- | $- | $- | |||||||||
| 19 | 62 | Health Care & Social Assistance | $- | $- | $- | |||||||||
| 20 | 71 | Arts, Entertainment & Recreation | $- | $- | $- | |||||||||
| 21 | 72 | Accommodation & Food Services | $- | $- | $- | |||||||||
| 22 | 81 | Other Services (except Public Administration) | $- | $- | $- | |||||||||
| 23 | 92 | Public Administration | $- | $- | $- | |||||||||
| 24 | N/A | Unavailable | $- | $- | $- | |||||||||
| 25 | SIC Code | 01-09 | Agriculture, Forestry & Fishing | $- | $- | $- | ||||||||
| 26 | 10-14 | Mining | $- | $- | $- | |||||||||
| 27 | 15-17 | Construction | $- | $- | $- | |||||||||
| 28 | 20-39 | Manufacturing | $- | $- | $- | |||||||||
| 29 | 40-49 | Transportation, Communications, Electric, Gas & Sanitary Services | $- | $- | $- | |||||||||
| 30 | 50-51 | Wholesale Trade | $- | $- | $- | |||||||||
| 31 | 52-59 | Retail Trade | $- | $- | $- | |||||||||
| 32 | 60-67 | Finance, Insurance & Real Estate | $- | $- | $- | |||||||||
| 33 | 70-89 | Services | $- | $- | $- | |||||||||
| 34 | 91-99 | Public Administration | $- | $- | $- | |||||||||
| 35 | N/A | Unavailable | $- | $- | $- | |||||||||
| 36 | TOTALS: | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| B | C | D | E | F | G | |
| 2 | Region | Description | Total 2016 Payroll Subject to TRIP Coverage under Primary WC Coverage | Total 2016 Payroll Subject to TRIP Coverage under Excess WC Coverage | Total 2016 Property Insurance Exposure Subject to TRIP Property Coverage | Total 2016 Property Insurance Exposure Not 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 through 01908, 01910, 01945, 01960, 01961, 01970, 01971; for Norfolk County only include zip codes 02026, 02027, 02030, 02062, 02090, 02169, 02170, 02171, 02184 through 02191, 02269, 02445, 02446, 02447, 02457, 02467, 02481, 02482, 02492, 02494; for Middlesex County only include zip codes 01701 through 01705, 01760, 01770, 01776, 01778, 01801, 01803, 01805 through 01808, 01813, 01815, 01866, 01867, 01880, 01888, 01890, 02138 through 02145, 02148, 02149, 02153, 02155, 02156, 02176, 02180, 02212, 02238, 02239, 02420, 02421, 02451 through 02456, 02458 through 02462, 02464 through 02468, 02471, 02472, 02474 through 02479, 02493, 02495. | ||||
| 6 | Buffalo, NY | All zip codes for Buffalo NY (14201 through 14228, 14231, 14233, 14240, 14241, 14260, 14261, 14263, 14264, 14265, 14267, 14269, 14270, 14272, 14273, 14276, 14280); Niagara Falls in Niagara county (14109, 14301, 14302, 14303, 14304, 14305); and include the nearby suburbs in Erie and Niagara counties (14010, 14026, 14031, 14032, 14037, 14043, 14051, 14059, 14068, 14075, 14086, 14120, 14127, 14140, 14150, 14151). | ||||
| 7 | Chicago, IL | All zip codes within the four counties of Cook, DuPage, Lake, and Will. | ||||
| 8 | Cleveland, OH | All zip codes within the two counties of Cuyahoga and Lake. | ||||
| 9 | Dallas/Ft. Worth, TX | All zip codes in the two counties of Dallas and Tarrant (Fort Worth). | ||||
| 10 | Denver, CO | All zip codes within the three counties of Adams, Arapahoe, and Denver. | ||||
| 11 | Detroit, MI | All zip codes within the three counties of Macomb, Oakland, and Wayne. | ||||
| 12 | Houston, TX | All zip codes in Harris County. | ||||
| 13 | Las Vegas, NV | All zip codes in Clark County. | ||||
| 14 | Los Angeles, CA | All zip codes within the two counties of Los Angeles and Orange. | ||||
| 15 | Miami, FL | All zip codes in Miami-Dade County. | ||||
| 16 | Minneapolis/St. Paul, MN | All zip codes in the two counties of Hennepin and Ramsey. | ||||
| 17 | New York, NY | All zip codes within the five counties of Kings (Brooklyn), Queens, New York (Manhattan), Bronx, and Richmond (Staten Island). | ||||
| 18 | Newark, NJ | All zip codes for the cities of Newark (07101 through 07108, 07112, 07114, 07175, 07182, 07184, 07188, 07189, 07191, 07192, 07193, 07194, 07195, 07198, 07199) and Elizabeth (07201, 07202, 07206, 07207, 07208). | ||||
| 19 | Orlando, FL | All zip codes in the two counties of Orange and Seminole. | ||||
| 20 | Philadelphia, PA | All zip codes in Philadelphia County. | ||||
| 21 | Phoenix, AZ | All zip codes in Maricopa County. | ||||
| 22 | San Diego, CA | All zip codes in San Diego County | ||||
| 23 | San Francisco, CA | All zip codes within the two counties of San Francisco and San Mateo. | ||||
| 24 | San Jose, CA | All zip codes in Santa Clara County. | ||||
| 25 | Seattle, WA | All zip codes in King County. | ||||
| 26 | St. Louis, MO | All zip codes within the two counties of St. Louis City and St. Louis. | ||||
| 27 | Tampa/St. Petersburg, FL | All zip codes in the two counties of Hillsborough and Pinellas. | ||||
| 28 | Washington, DC | All zip codes within Washington D.C. and all zip codes within the two counties of Arlington, VA and Alexandria City, VA. | ||||
| 29 | All other Locations in the U.S. | All areas in the US other than those specified in Cells C3-C28 | ||||
| 30 | Unknown | If locations are unknown for a policy, enter the requested information here. | ||||
| 31 | Subtotal | All metro regions specified in Cells C3-C28 | $- | $- | $- | $- |
| 32 | Total | All metro regions and other locations specified in Cells C3-C30 | $- | $- | $- | $- |
| Top 5 Largest Accumulated Exposure Locations (Metro Regions, (Rows C3 to C28) |
Payroll Exposure | Property Exposure | ||||
| 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 Property Insurance Exposure subject to TRIP Property Coverage | Amount of Top 5 Largest Accumulated Exposure Locations by Property Insurance Exposure subject to TRIP Property Coverage | |||
| 35 | 1 | |||||
| 36 | 2 | |||||
| 37 | 3 | |||||
| 38 | 4 | |||||
| 39 | 5 | |||||
| Top 5 Largest Accumulated Exposure Locations (All Other Non-Metro Areas, (Rows C29-C30) |
Payroll Exposure | Property Exposure | ||||
| 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 Property Insurance Exposure subject to TRIP Property Coverage | Amount of Top 5 Largest Accumulated Exposure Locations by Property Insurance Exposure subject to TRIP Property Coverage | |||
| 43 | 1 | |||||
| 44 | 2 | |||||
| 45 | 3 | |||||
| 46 | 4 | |||||
| 47 | 5 | |||||
| 49 | ZIP Code Associated with Largest Probable Maximum Loss (PML) | |||||
| 50 | Largest PML at a Single Location (Amount) | |||||
| 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? | ||
| 28 | Using the following defined terrorism event, calculate and report the total projected loss under policies containing terrorism risk insurance subject to TRIP issued by the Group or Company, and then within that figure report the following: (1) the deductible or retention obligations of insureds under triggered policies for the insurer group (or single company that is not part of a group); (2) the projected amount of net loss the insurer group (or single company that is not part of a group) will sustain within its TRIP deductible, net of policyholder obligations or private reinsurance; (3) any private reinsurance recovery available to the group or company within the TRIP deductible; (4) the amount of the group or company's claim under TRIP; (5) the amount of the group or company's continuing net co-pay obligation under TRIP; and (6) any private reinsurance recovery available to the group or company within the Co-Pay Layer. The scenario is a 2.5-7.5 ton truck bomb detonates at Rockefeller Center (45 Rockefeller Plaza, New York, NY 10111) on June 7, 2016 (a Tuesday) at 11:00 AM. Further assume that the loss does not involve any NBCR exposures. Assume that the loss resulting from the explosion is characterized by the estimates below; however, if your group or company typically utilizes different damage assumptions for an explosion of this magnitude, please use those alternative assumptions: · Zone 1 (200 meters from site): Collapse and fire following, 100% property damage and 10% fire loss · Zone 2 (400 meters from site): Massive debris damage to surrounding properties (25% property damage, 2.5% fire loss) · Zone 3 (500 meters from site): Light debris damage to surrounding properties (10% property damage, 1% fire loss) · Injuries: 2,000 blue/white-collar worker deaths in total and 4,000 injuries in total |
||
| 29 | Total Projected Loss under Policies Issued by Group or Company | $- | |
| 30 | Deductible/Retention of Insureds under Policies issued by Group or Company | ||
| 31 | Net Loss to Group or Company within TRIP Deductible | ||
| 32 | Private Reinsurance Recovery within Deductible Layer | ||
| 33 | Claim under TRIP | ||
| 34 | Net Loss to Group or Company within Co-Pay Layer | ||
| 35 | Private Reinsurance Recovery within Co-Pay Layer | ||
| Notice under the Paperwork Reduction Act We estimate it will take you about 50 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. |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |