Terrorism Risk Insurance Program: Captive Insurers

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OMB No. 1505-0257
Expiration: __________

3

B
Group Code (NAIC or as
assigned by Aggregator)

TERRORISM RISK INSURANCE PROGRAM 2019 DATA CALL: CAPTIVE INSURERS
INSURER GROUP AFFILIATIONS

C

G
3 Total 2017 Policyholder Surplus:

Insurer Group Name

4

B
Company Code (NAIC or as
8 assigned by Aggregator)
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

4 Total 2017 TRIP-Eligible DEP (all lines):

C

D

E

Insurance Company Name

Type of Insurer

Domicile

Affiliations
Page 1 of 13

H

OMB No. 1505-0257
Expiration: __________

TERRORISM RISK INSURANCE PROGRAM 2019 DATA CALL: CAPTIVE INSURERS
DIRECT EARNED PREMIUM (DEP) (JURISDICTION)

Jurisdiction:
2
B

5
TRIP-Eligible Line of Coverage
6 Fire
7 Allied Lines
8 Commercial Multiple Peril (non-liability portion)
9 Commercial Multiple Peril (liability portion)
10 Ocean Marine
11 Inland Marine
12 Workers' Compensation
13 Workers' Compensation Deductible Reimbursement
14 Excess Workers' Compensation
15 Other Liability
16 Products Liability
17 Aircraft (all perils)
18 Boiler and Machinery
19 TOTALS

C

NAIC Line
(Commercial
Only)
1
2.1
5.1
5.2
8
9
16
16
17.3
17
18
22
27

D

E

F

G

H

Total 2018 TRIP- Total 2018 TRIP-Eligible Total 2018 TRIP-Eligible
Total 2018 TRIPEligible DEP
DEP (Terrorism Risk
DEP (Terrorism Risk Total 2018 DEP Charged
Eligible DEP (all
(Terrorism Risk
Coverage Provided for Coverage Provided with
for Terrorism Risk
policies)
Coverage Declined) Disclosed $0 Charge)
a Premium Charged)
Coverage
$
$
$
$
$
$
$
$
$
$
$
$
$
$
- $
- $
- $
- $
-

Premium (Juris.)
Page 2 of 13

OMB No. 1505-0257
Expiration: _________

TERRORISM RISK INSURANCE PROGRAM 2019 DATA CALL: CAPTIVE INSURERS
STANDALONE TERRORISM (NATIONWIDE)
B
Element

2
3 2018 DEP for Standalone Terrorism Policies
4 Portion of 2018 DEP Providing Coverage for Losses for Certified Acts of Terrorism under TRIP
Portion of 2018 DEP Providing Coverage for Losses Arising from Other (Non-Certified) Acts of
5
Terrorism
6 2018 Number of Standalone Terrorism Policies Issued
2018 Number of Standalone Terrorism Policies Issued Providing Coverage for Losses for Certified Acts
7
of Terrorism under TRIP
2018 Property Insurance Exposure for Standalone Terrorism Policies Providing Coverage for Losses
8
for Certified Acts of Terrorism under TRIP
Total 2018 Limits of Liability for Standalone Terrorism Policies Providing Coverage for Losses for
9
Certified Acts of Terrorism under TRIP

Standalone Terrorism (US)
Page 3 of 13

C
Amount

TERRORISM RISK iNSURANCE PROGRAM 2019 DATA CALL: CAPTIVE INSURERS
CYBER (NATIONWIDE)

OMB No. 1505-0257
Expiration: __________
B

2
Element
3 Total 2018 TRIP-Eligible DEP (All Cyber Policies)
4 Total 2018 TRIP-Eligible DEP for Cyber Policies (Terrorism Risk Coverage Declined)
5 Total 2018 TRIP-Eligible DEP for Cyber Policies (Terrorism Risk Coverage Provided)
6 Total 2018 DEP Charged for Terrorism Risk Coverage Under Cyber Policies
7 Total 2018 Number of Cyber Policies Issued
8 Total 2018 Number of Cyber Policies Issued (Terrorism Risk Coverage Provided)
Total 2018 Limits of Liability for Cyber Policies Providing Coverage for Losses for Certified Acts
9
of Terrorism Under TRIP

C

D

E

Standalone Cyber

Cyber Coverage
Provided as Part of
a Package Policy

Totals
$
$

0
0
0

$

-

OMB No. 1505-0257
Expiration: ___________

TERRORISM RISK INSURANCE PROGRAM 2019 DATA CALL: CAPTIVE INSURERS
EXPOSURE BASES BY JURISDICTION

Jurisdiction:
2
B

5
TRIP-Eligible Line of Coverage
6 Fire
7 Allied Lines
8 Commercial Multiple Peril (non-liability portion)
9 Commercial Multiple Peril (liability portion)
10 Ocean Marine
11 Inland Marine
12 Workers' Compensation
13 Workers' Compensation Deductible Reimbursement
14 Excess Workers' Compensation
15 Other Liability
16 Products Liability
17 Aircraft (all perils)
18 Boiler and Machinery
19 TOTALS

C

D

E

F

G

H

I

J

K

L

M

N

O

Total 2018 TRIP-Eligible
Total 2018 TRIP-Eligible
Total 2018 Limits of
Property Exposure Total 2018 Policyholder
Total 2018 Policyholder Total 2018 Limits of
Limits of Liability
Total 2018 Policyholder
Liability for TRIPTotal 2018 Policyholder
Total 2018 TRIP-Eligible
(Terrorism Risk
Deductibles for TRIP- Total 2018 TRIP-Eligible Deductibles for TRIPLiability for TRIP(Terrorism Risk
Deductibles for TRIPEligible Policies
Deductibles for TRIP- Total 2018 Payroll for
NAIC Line
Property Exposure Coverage Provided and
Eligible Property
Property Exposure
Eligible Property
Eligible Policies
Coverage Provided and
Eligible Liability
Exposure (Terrorism
Eligible Liability
TRIP-Eligible Policies Total 2018 Payroll Not
(Commercial
(Terrorism Risk
NBCR Risks Not
Policies (Terrorism Risk
(Terrorism Risk
Policies (Terrorism Risk
(Terrorism Risk
NBCR Risks Not
Policies (Terrorism Risk
Risk Coverage
Policies (Terrorism Risk
(Terrorism Risk
Subject to Terrorism
Only)
Coverage Provided)
Excluded)
Coverage Provided)
Coverage Declined)
Coverage Declined)
Coverage Provided)
Excluded)
Coverage Provided)
Declined)
Coverage Declined)
Coverage Provided)
Risk Coverage
1
2.1
5.1
5.2
8
9
16
16
17.3
17
18
22
27
$
- $
- $
- $
- $
- $
- $
- $
- $
- $
- $
- $
-

Exposure Bases (Juris.)
Page 5 of 13

OMB No. 1505-0257
Expiration: ______

TERRORISM RISK INSURANCE PROGRAM 2019 DATA CALL: CAPTIVE INSURERS
POLICYHOLDER INDUSTRY CODE (Nationwide)
A

2

NAICS Code Number Most Applicable to the
Business(es) Insured by the Captive Insurer:

B

OMB No. 1505-0257
Expiration: _______

TERRORISM RISK INSURANCE PROGRAM 2019 DATA CALL: CAPTIVE INSURERS
GEOGRAPHIC EXPOSURES (NATIONWIDE)

B

2
Region
3 Atlanta. GA

C

Description
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
8 Cleveland, OH
9 Dallas/Ft. Worth, TX
10 Denver, CO
11 Detroit, MI
12 Houston, TX
13 Las Vegas, NV
14 Los Angeles, CA
15 Miami, FL
Minneapolis/St. Paul,
16
MN

D
E
F
G
Total 2018 Payroll for
Total 2018 Payroll for
TRIP-Eligible Primary WC TRIP-Eligible Primary WC Total 2018 TRIP-Eligible Total 2018 TRIP-Eligible
and Excess WC Policies
and Excess WC Policies
Property Exposure
Property Exposure
(Terrorism Risk Coverage (Terrorism Risk Coverage (Terrorism Risk Coverage (Terrorism Risk Coverage
Provided)
Not Provided)
Provided)
Declined)

All zip codes within the four counties of Cook, DuPage, Lake, and Will.
All zip codes in the counties of Cuyahoga and Lake.
All zip codes in the two counties of Dallas and Tarrant (Fort Worth).
All zip codes in the three counties of Adams, Arapahoe, and Denver.
All zip codes in the three counties of Macomb, Oakland, and Wayne.
All zip codes in Harris County.
All zip codes in Clark County.
All zip codes within the two counties of Los Angeles and Orange.
All zip codes in Miami-Dade County.
All zip codes in the two counties of Hennepin and Ramsey.

Geographic (US)
Page 7 of 13

OMB No. 1505-0257
Expiration: _______
17 New York, NY
18 Newark, NJ

TERRORISM RISK INSURANCE PROGRAM 2019 DATA CALL: CAPTIVE INSURERS
GEOGRAPHIC EXPOSURES (NATIONWIDE)
All zip codes within the five counties of Kings (Brooklyn), Queens, New York
(Manhattan), Bronx, and Richmond (Staten Island).
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).

All zip codes in the two counties of Orange and Seminole.
19 Orlando, FL
All zip codes in Philadelphia County.
20 Philadelphia, PA
All zip codes in Maricopa County.
21 Phoenix, AZ
All zip codes in San Diego County
22 San Diego, CA
All zip codes within the two counties of San Francisco and San Mateo.
23 San Francisco, CA
All zip codes in Santa Clara County.
24 San Jose, CA
All zip codes in King County.
25 Seattle, WA
All zip codes in the two counties of St. Louis City and St. Louis.
26 St. Louis, MO
Tampa/St. Petersburg,
All zip codes in the two counties of Hillsborough and Pinellas.
27
FL

28 Washington, DC
All other Locations in
the U.S.
30 Unknown
31 Subtotal
32 Total
29

All zip codes within Washington D.C. and all zip codes within the two counties of
Arlington, VA and Alexandria City, VA.
All areas in the US other than those specified in Cells C3-C28
If locations are unknown for a policy, enter the requested information here.
All metro regions specified in Cells C3-C28
All metro regions and other locations specified in Cells C3-C30

$
$

- $
- $

Geographic (US)
Page 8 of 13

- $
- $

- $
- $

-

OMB No. 1505-0257
Expiration: _______

TERRORISM RISK INSURANCE PROGRAM 2019 DATA CALL: CAPTIVE INSURERS
GEOGRAPHIC EXPOSURES (NATIONWIDE)
Payroll Exposure

Property Exposure
ZIP Code of Top 5 Largest Amount of Top 5 Largest
Accumulated Exposure
Accumulated Exposure
Locations by Property
Locations by Property
Insurance Exposure
Insurance Exposure
Amount of Top 5 Largest (Terrorism Risk Coverage (Terrorism Risk Coverage
ZIP Code of Top 5 Largest Accumulated Exposure Locations Accumulated Exposure Provided) (Metropolitan Provided) (Metropolitan
Areas)
Areas)
by Payroll
Locations by Payroll

Top 5 Largest
Accumulated Exposure
Locations
(Metro Areas,
(Rows C3 to C28)
35
36
37
38
39

1
2
3
4
5
Payroll Exposure

Top 5 Largest
Accumulated Exposure
Locations
(All Other Non-Metro
Areas,
(Rows C29-C30)
43
44
45
46
47

Property Exposure

ZIP Code of Top 5 Largest Amount of Top 5 Largest
Accumulated Exposure
Accumulated Exposure
Locations by Property
Locations by Property
Insurance Exposure
Insurance Exposure
Amount of Top 5 Largest (Terrorism Risk Coverage (Terrorism Risk Coverage
ZIP Code of Top 5 Largest Accumulated Exposure Locations Accumulated Exposure
Provided) (NonProvided)(Nonby Payroll
Locations by Payroll
Metropolitan Areas)
Metropolitan Areas)
1
2
3
4
5

49 ZIP Code Associated with Largest Probable Maximum Loss (PML)
50 Largest PML at a Single Location (Amount)

Geographic (US)
Page 9 of 13

OMB No. 1505-0257
Expiration: ___________

TERRORISM RISK INSURANCE PROGRAM 2019 DATA CAll: CAPTIVE INSURERS
REINSURANCE (NATIONWIDE)

B
2
Element
3 Size of TRIP 2018 Deductible (Cell H4 of Insurer Group Affiliations Chart x 20%)
4 Total 2018 Limits Any One Loss of Purchased Treaty Reinsurance Covering TRIP Loss
5 Total 2018 Aggregate Limits of Purchased Treaty Reinsurance Covering TRIP Loss
6 2018 Attachment Point Any One Loss of Purchased Treaty Reinsurance Covering TRIP Loss
7 2018 Co-Participation Share Any One Loss of Purchased Treaty Reinsurance Covering TRIP Loss
8 Total 2018 Limits Any One Loss of Purchased Treaty Reinsurance Covering Natural Catastrophic Loss
9 Total 2018 Aggregate Limits of Purchased Treaty Reinsurance Covering Natural Catastrophic Loss
10 2018 Attachment Point Any One Loss of Purchased Treaty Reinsurance Covering Natural Catastrophic Loss
11 2018 Co-Participation Share Any One Loss 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, 2018 Limits Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving WC Loss
If Yes, 2018 Attachment Point Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism
involving WC Loss
16
If Yes, 2018 Co-Participation Share (if any) Any One Loss of NBCR Reinsurance For Certified Acts of
Terrorism involving WC Loss
17
18 Reinsurance for NBCR Property Loss Resulting from Certified Acts of Terrorism?
If Yes, 2018 Limits Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving Property
Loss
19
If Yes, 2018 Attachment Point Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism
20
involving Property Loss
If Yes, 2018 Co-Participation Share (if any) Any One Loss of NBCR Reinsurance for Certified Acts of
Terrorism involving Property Loss
21
22 Reinsurance for NBCR Liability Loss Resulting from Certified Acts of Terrorism?
If Yes, 2018 Limits Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving Liability
Loss
23
If Yes, 2018 Attachment Point Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism
involving Liability Loss
24
If Yes, 2018 Co-Participation Share (if any) Any One Loss of NBCR Reinsurance for Certified Acts of
25
Terrorism involving Liability Loss
26 Any Other Reinsurance Exclusions Specifically Applicable to Certified Acts of Terrorism Under TRIP?

Reinsurance (US)
Page 10 of 13

C
Response

D
Description or Explanation (if any)

OMB No. 1505-0257
Expiration: ___________

TERRORISM RISK INSURANCE PROGRAM 2019 DATA CAll: CAPTIVE INSURERS
REINSURANCE (NATIONWIDE)

Using the following defined terrorism event (which should be considered to be a single event, loss, or occurrence for purpose of calculating applicable deductibles and policy limits), calculate and report the total
projected loss (dividing the loss associated with the two identified explosions as indicated) under property and workers' compensation policies containing terrorism risk insurance subject to TRIP issued by the
Group or Company, and then within that figure report the following (Note: To the extent a figure is subject to a single limit between Location A and Location B, such as the TRIP Deductible, allocate as
appropriate between Location A and Location B depending upon where the loss figures fall).
(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.

27

Location A: On May 20, 2018 (a Monday), at 11:30 a.m., a 5-6 ton truck bomb detonates at Embarcadero Center (at the corner of Sacramento and Front Streets) in San Francisco, California 94111. 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
-Casualties: 2,000 total worker deaths plus 4,000 total worker injuries.
Location B: Also on May 20, 2018, at 12:30 PM, a car bomb explodes at Union Square (at the corner of Geary and Powell Streets) in San Francisco, California 94108. The car contains 2-3 pounds of Cesium-137,
which is dispersed into the atmosphere by the blast. Again, 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. The dispersal of radiological material is identified shortly after the blast by fixed radiation monitoring devices in the
city. The zone of actual and threatened dispersal of the Cesium-137 is an area bounded by Broadway, Highway 101, and Interstate 80 ("dispersal zone"). 50 percent of all workers in the dispersal zone (not
including any killed by the blast at Location A) request or are provided medical monitoring. 500 workers in total (not including any of those injured by the blast at Location A) develop short and long-term
injuries associated with radiation exposure (your exposure should be based upon your estimate of your market share of this total number of employees). The blast itself (apart from the dispersal of radiological
material) causes no injuries, deaths, or physical property damage, apart from damage to the vehicle. Responsible governmental authorities prohibit access to the dispersal area for a period of 90 days while
recovery operations are conducted, debris is cleared, clean-up crews conduct decontamination operations, and utilities, services, and access is restored.

Reinsurance (US)
Page 11 of 13

OMB No. 1505-0257
Expiration: ___________

TERRORISM RISK INSURANCE PROGRAM 2019 DATA CAll: CAPTIVE INSURERS
REINSURANCE (NATIONWIDE)
Location A

30 Total Projected Loss under Policies Issued by Group or Company
31 Deductible/Retention of Insureds under Policies issued by Group or Company
32 Net Loss to Group or Company within TRIP Deductible
33 Private Reinsurance Recovery within Deductible Layer
34 Claim under TRIP
35 Net Loss to Group or Company within Co-Pay Layer
36 Private Reinsurance Recovery within Co-Pay Layer

$

Reinsurance (US)
Page 12 of 13

Location B
- $

Total (Locations A and B)
-$
$
$
$
$
$
$

-

Notice under the Paperwork Reduction Act
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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