| B | C | G | H | |||||
| 3 | Group Code (NAIC or as assigned by Aggregator) | Insurer Group Name | 3 | Total 2016 Policyholder Surplus: | ||||
| 4 | 4 | Total 2016 TRIP-Eligible DEP (all lines): | ||||||
| B | C | D | E | |||||
| 8 | Company Code (NAIC or as assigned by Aggregator) | Insurance Company Name | Type of Insurer | Domicile | ||||
| 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 | |
| 5 | TRIP-Eligible Line of Coverage | NAIC Line (Commercial Only) | Total 2017 TRIP-Eligible DEP (all policies) | Total 2017 TRIP-Eligible DEP (Terrorism Risk Coverage Declined) | Total 2017 TRIP-Eligible DEP (Terrorism Risk Coverage Provided for Disclosed $0 Charge) | Total 2017 TRIP-Eligible DEP (Terrorism Risk Coverage Provided with a Premium Charged) | Total 2017 DEP Charged for 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 | Workers' Compensation Deductible Reimbursement | 16 | $- | ||||
| 14 | Excess Workers' Compensation | 17.3 | $- | ||||
| 15 | Other Liability | 17 | $- | ||||
| 16 | Products Liability | 18 | $- | ||||
| 17 | Aircraft (all perils) | 22 | $- | ||||
| 18 | Boiler and Machinery | 27 | $- | ||||
| 19 | TOTALS | $- | $- | $- | $- | $- | |
| B | C | |
| 2 | Element | Amount |
| 3 | 2017 DEP for Standalone Terrorism Policies | |
| 4 | Portion of 2017 DEP Providing Coverage for Losses for Certified Acts of Terrorism under TRIP | |
| 5 | Portion of 2017 DEP Providing Coverage for Losses Arising from Other (Non-Certified) Acts of Terrorism | |
| 6 | 2017 Number of Standalone Terrorism Policies Issued | |
| 7 | 2017 Number of Standalone Terrorism Policies Issued Providing Coverage for Losses for Certified Acts of Terrorism under TRIP | |
| 8 | 2017 Property Insurance Exposure for Standalone Terrorism Policies Providing Coverage for Losses for Certified Acts of Terrorism under TRIP | |
| 9 | 2017 Total Limits of Liability for Standalone Terrorism Policies Providing Coverage for Losses for Certified Acts of Terrorism under TRIP |
| B | C | D | E | |
| 2 | Element | Standalone Cyber | Cyber Coverage Provided as Part of a Package Policy | Totals |
| 3 | 2017 TRIP-Eligible DEP for Cyber Policies | |||
| 4 | 2017 TRIP-Eligible DEP for Cyber Policies (Terrorism Risk Coverage Declined) | |||
| 5 | 2017 TRIP-Eligible DEP for Cyber Policies (Terrorism Risk Coverage Provided) | |||
| 6 | 2017 Total Disclosed Terrorism Risk Coverage DEP Charged Under Cyber Policies | |||
| 7 | 2017 Number of Cyber Policies Issued | |||
| 8 | 2017 Number of Cyber Policies Issued (Terrorism Risk Coverage Provided) | |||
| 9 | 2017 Total Liability Policy Limits for Cyber Policies (Terrorism Risk Coverage Provided) |
| Jurisdiction: | ||||||||||||
| 2 | ||||||||||||
| B | C | D | E | F | G | H | I | J | K | L | M | |
| 5 | TRIP-Eligible Line of Coverage | NAIC Line (Commercial Only) | Total 2017 TRIP-Eligible Property Exposure (Terrorism Risk Coverage Provided) | Total 2017 Policyholder Deductibles for TRIP-Eligible Property Policies (Terrorism Risk Coverage Provided) | Total 2017 TRIP-Eligible Property Exposure (Terrorism Risk Coverage Declined) | Total 2017 Policyholder Deductibles for TRIP-Eligible Property Policies (Terrorism Risk Coverage Declined) | Total 2017 TRIP-Eligible Liability Exposure (Terrorism Risk Coverage Provided) | Total 2017 Policyholder Deductibles for TRIP-Eligible Liability Policies (Terrorism Risk Coverage Provided) | Total 2017 TRIP-Eligible Liability Exposure (Terrorism Risk Coverage Declined) | Total 2017 Policyholder Deductibles for TRIP-Eligible Liability Policies (Terrorism Risk Coverage Declined) | Total 2017 Payroll for TRIP-Eligible Policies (Terrorism Risk Coverage Provided) | Total 2017 Payroll Not 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 | Workers' Compensation Deductible Reimbursement | 16 | ||||||||||
| 14 | Excess Workers' Compensation | 17.3 | ||||||||||
| 15 | Other Liability | 17 | ||||||||||
| 16 | Products Liability | 18 | ||||||||||
| 17 | Aircraft (all perils) | 22 | ||||||||||
| 18 | Boiler and Machinery | 27 | ||||||||||
| 19 | TOTALS | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |
| A | B | |
| 2 | NAICS Code Number Most Applicable to the Business(es) Insured by the Captive Insurer: | |
| B | C | D | E | F | G | |
| 2 | Region | Description | Total 2017 Payroll Subject to TRIP Coverage under WC Coverage (Primary WC or Excess WC) | Total 2017 Payroll Not Subject TRIP Coverage under WC Coverage (Primary WC or Excess WC) | Total 2017 Property Insurance Exposure (Terrorism Risk Coverage Provided) | Total 2017 Property Insurance Exposure (Terrorism Risk Coverage Declined) |
| 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 in the 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 in the three counties of Adams, Arapahoe, and Denver. | ||||
| 11 | Detroit, MI | All zip codes in 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 in 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 Areas, (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 (Terrorism Risk Coverage Provided) (Metropolitan Areas) | Amount of Top 5 Largest Accumulated Exposure Locations by Property Insurance Exposure (Terrorism Risk Coverage Provided) (Metropolitan Areas) | |||
| 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 (Terrorism Risk Coverage Provided) (Non-Metropolitan Areas) | Amount of Top 5 Largest Accumulated Exposure Locations by Property Insurance Exposure (Terrorism Risk Coverage Provided)(Non-Metropolitan Areas) | |||
| 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 2017 Deductible (Cell H4 of Insurer Group Affiliations Chart x 20%) | ||
| 4 | Total 2017 Limits Any One Loss of Purchased Treaty Reinsurance Covering TRIP Loss | ||
| 5 | Total 2017 Aggregate Limits of Purchased Treaty Reinsurance Covering TRIP Loss | ||
| 6 | 2017 Attachment Point of Purchased Treaty Reinsurance Covering TRIP Loss | ||
| 7 | 2017 Co-Participation Share of Purchased Treaty Reinsurance Covering TRIP Loss | ||
| 8 | Total 2017 Limits Any One Loss of Purchased Treaty Reinsurance Covering Natural Catastrophic Loss | ||
| 9 | Total 2017 Aggregate Limits of Purchased Treaty Reinsurance Covering Natural Catastrophic Loss | ||
| 10 | 2017 Attachment Point of Purchased Treaty Reinsurance Covering Natural Catastrophic Loss | ||
| 11 | 2017 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 2017 Limits of NBCR Reinsurance for Certified Acts of Terrorism involving WC Loss | ||
| 16 | If Yes, 2017 Attachment Point of NBCR Reinsurance for Certified Acts of Terrorism involving WC Loss | ||
| 17 | If Yes, 2017 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 2017 Limits of NBCR Reinsurance for Certified Acts of Terrorism involving Property Loss | ||
| 20 | If Yes, 2017 Attachment Point of NBCR Reinsurance for Certified Acts of Terrorism involving Property Loss | ||
| 21 | If Yes, 2017 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 2017 Limits of NBCR Reinsurance for Certified Acts of Terrorism involving Liability Loss | ||
| 24 | If Yes, 2017 Attachment Point of NBCR Reinsurance for Certified Acts of Terrorism involving Liability Loss | ||
| 25 | If Yes, 2017 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? | ||
| 27 | 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 involves two separate, but related, attacks placing place on October 13, 2017 (a Friday). 1. At 11:00 a.m., a group of five terrorists detonate five suitcase bombs carried in luggage carts in the main departure area of Terminal 3 at O'Hare International Airport. Use the following estimates in calculating damages: -The departure area sustains massive debris damage (50% property damage, 1% fire loss) -Injuries: 25 blue/white collar worker deaths in total, and 100 injuries in total -Assume that all of O'Hare Airport is closed for 7 days, and Terminal 3 is closed for 60 days. 2. At 11:30 a.m., a 5-6 ton truck bomb detonates at Willis Tower (233 S. Wacker Drive, Chicago, IL 60606). Assume that the loss does not involve any NBCR exposures. Assume also 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 (100 meters from site): Collapse and fire following, 100% property damage, 10% fire loss -Zone 2 (200 meters from site): Massive structural damage to surrounding properties, 50% property damage, 5% fire loss -Zone 3 (400 meters from site): Heavy debris damage to surrounding properties, 25% property damage, 2.5% fire loss -Zone 4 (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 |
||
| 28 | Total Projected Loss under Policies Issued by Group or Company | $- | |
| 29 | Deductible/Retention of Insureds under Policies issued by Group or Company | ||
| 30 | Net Loss to Group or Company within TRIP Deductible | ||
| 31 | Private Reinsurance Recovery within Deductible Layer | ||
| 32 | Claim under TRIP | ||
| 33 | Net Loss to Group or Company within Co-Pay Layer | ||
| 34 | 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.tripsection111data.com |
| Premium | Exposure |
| Alabama | United States |
| Alaska | Alabama |
| American Samoa | Alaska |
| Arizona | American Samoa |
| Arkansas | Arizona |
| California | Arkansas |
| Colorado | California |
| Connecticut | Colorado |
| Delaware | Connecticut |
| District of Columbia | Delaware |
| Florida | District of Columbia |
| Georgia | Florida |
| Guam | Georgia |
| Hawaii | Guam |
| Idaho | Hawaii |
| Illinois | Idaho |
| Indiana | Illinois |
| Iowa | Indiana |
| Kansas | Iowa |
| Kentucky | Kansas |
| Louisiana | Kentucky |
| Maine | Louisiana |
| Maryland | Maine |
| Massachusetts | Maryland |
| Michigan | Massachusetts |
| Minnesota | Michigan |
| Mississippi | Minnesota |
| Missouri | Mississippi |
| Montana | Missouri |
| Nebraska | Montana |
| Nevada | Nebraska |
| New Hampshire | Nevada |
| New Jersey | New Hampshire |
| New Mexico | New Jersey |
| New York | New Mexico |
| North Carolina | New York |
| North Dakota | North Carolina |
| Northern Mariana Islands | North Dakota |
| Ohio | Northern Mariana Islands |
| Oklahoma | Ohio |
| Oregon | Oklahoma |
| Puerto Rico | Oregon |
| Pennsylvania | Puerto Rico |
| Rhode Island | Pennsylvania |
| South Carolina | Rhode Island |
| South Dakota | South Carolina |
| Tennessee | South Dakota |
| Texas | Tennessee |
| U.S. Virgin Islands | Texas |
| Utah | U.S. Virgin Islands |
| Vermont | Utah |
| Virginia | Vermont |
| Washington | Virginia |
| West Virginia | Washington |
| Wisconsin | West Virginia |
| Wyoming | Wisconsin |
| Other/Not Subject to Allocation in a Particular Jurisdiction | Wyoming |
| Other/Not Subject to Allocation in a Particular Jurisdiction |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |