TRIP 04B Direct Written Premium and End of Year Calcuation

Control Number

(Treasury use)

TERRORISM RISK INSURANCE PROGRAM

DIRECT WRITTEN PREMIUM AND END OF YEAR CALCULATION

1. Insurer Name:

2. NAIC Insurer Number (or TIN if no NAIC #):

3. Calendar Year of Direct Written Premium (see instructions for guidance):

4. Submitted for Period Ending: E. Type of submission: Original Correction

6. Step One A:

Enter the insurer’s Direct Written Premium for commercial lines of business (listed below) as would typically be reported in Column 1 of the Exhibit of Premiums and Losses of the NAIC Annual Statement (Statutory Page 14), or from another appropriate reporting mechanism. Columns 1B and 1C must sum to equal Column 1A. All entries should be provided in whole dollars.

Annual Statement Line of Business		- Column 1A -		- Column 1B -		- Column 1C -
		Premium Reported on Statutory Page 14 or Equivalent Calendar Year 20xx		Premium Prior to Assessment Period Calendar Year 20xx (if applicable)		Premium During Assessment Period Calendar Year 20xx
Line 1 – Fire	$		$		$
Line 2.1 – Allied Lines	$		$		$
Line 5.1 – Commercial Multiple Peril (non-liability portion)	$		$		$
Line 5.2 – Commercial Multiple Peril (liability portion)	$		$		$
Line 8 – Ocean Marine	$		$		$
Line 9 – Inland Marine	$		$		$
Line 16 – Workers’ Compensation	$		$		$
Line 17 – Other Liability	$		$		$
Line 18 – Products Liability	$		$		$
Line 22 – Aircraft (all perils)	$		$		$
Line 27 – Boiler and Machinery	$		$		$
	$		$		$
	$		$		$
	$		$		$
	$		$		$
	$		$		$
	$		$		$
	$		$		$

(add more rows as needed)

6. Step One B:

Enter the insurer’s Direct Written Premium for commercial lines of business (listed below) as would typically be reported in Column 1C in Step One A. Columns 2 through 5 should sum to equal Column 1C. However, if necessary, additional columns (and sheets) may be added to complete the breakout of premium by policy year and to fully account for the entry in Column 1C. All entries should be provided in whole dollars.

Annual Statement Line of Business		- Column 1C -		- Column 2 -		- Column 3 -		- Column 4 -		- Column 5 -
		Premium During Assessment Period CY 20xx		Policy Year 20xx		Prior Policy Year (20xx – 1 year)		Prior Policy Year (20xx – 2 years)		Prior Policy Year (20xx – 3 years)
Line 1 – Fire	$		$		$		$		$
Line 2.1 – Allied Lines	$		$		$		$		$
Line 5.1 – Commercial Multiple Peril (non-liability portion)	$		$		$		$		$
Line 5.2 – Commercial Multiple Peril (liability portion)	$		$		$		$		$
Line 8 – Ocean Marine	$		$		$		$		$
Line 9 – Inland Marine	$		$		$		$		$
Line 16 – Workers’ Compensation	$		$		$		$		$
Line 17 – Other Liability	$		$		$		$		$
Line 18 – Products Liability	$		$		$		$		$
Line 22 – Aircraft (all perils)	$		$		$		$		$
Line 27 – Boiler and Machinery	$		$		$		$		$
	$		$		$		$		$
	$		$		$		$		$
	$		$		$		$		$
	$		$		$		$		$
	$		$		$		$		$
	$		$		$		$		$
	$		$		$		$		$

(add more rows as needed)

STEP ONE TOTALS:

$

$

$

$

$

6. Step Two:

Enter premium included in the Direct Written Premium numbers reported in Column 1C under Step One B that is for insurance coverage not subject to the Federal Terrorism Policy Surcharge. Columns 2 through 5 should sum to equal Column 1C. However, if necessary, additional columns (and sheets) may be added to complete the breakout of premium by policy year and to fully account for the entry in Column 1C. All entries should be provided in whole dollars.

Annual Statement Line of Business		- Column 1C -		- Column 2 -		- Column 3 -		- Column 4 -		- Column 5 -
		Premium During Assessment Period CY 20xx		Policy Year 20xx		Prior Policy Year (20xx – 1 year)		Prior Policy Year (20xx – 2 years)		Prior Policy Year (20xx – 3 years)
Line 1 – Fire	$		$		$		$		$
Line 2.1 – Allied Lines	$		$		$		$		$
Line 5.1 – Commercial Multiple Peril (non-liability portion)	$		$		$		$		$
Line 5.2 – Commercial Multiple Peril (liability portion)	$		$		$		$		$
Line 8 – Ocean Marine	$		$		$		$		$
Line 9 – Inland Marine	$		$		$		$		$
Line 16 – Workers’ Compensation	$		$		$		$		$
Line 17 – Other Liability	$		$		$		$		$
Line 18 – Products Liability	$		$		$		$		$
Line 22 – Aircraft (all perils)	$		$		$		$		$
Line 27 – Boiler and Machinery	$		$		$		$		$
	$		$		$		$		$
	$		$		$		$		$
	$		$		$		$		$
	$		$		$		$		$
	$		$		$		$		$
	$		$		$		$		$
	$		$		$		$		$

(add more rows as needed)

STEP TWO TOTALS:

$

$

$

$

$

6. Step Three:

Complete the following formulas to determine the insurer’s cumulative Direct Written Premium, for the applicable period, subject to the Federal Terrorism Policy Surcharge.

		- Column 1C -		- Column 2 -		- Column 3 -		- Column 4 -		- Column 5 -
		Premium During Assessment Period CY 20xx		Policy Year 20xx		Prior Policy Year (20xx – 1 year)		Prior Policy Year (20xx – 2 years)		Prior Policy Year (20xx – 3 years)
Step One B Totals (as applicable)	$		$		$		$		$
SUBTRACT Step Two Totals (as applicable)	$		$		$		$		$
EQUALS Premium Subject to Surcharge	$		$		$		$		$

6. Step Four:

Complete the following formulas to determine the insurer’s Federal Terrorism Policy Surcharge for the applicable year.

		- Column 1C -		- Column 2 -		- Column 3 -		- Column 4 -		- Column 5 -
		Premium During Assessment Period CY 20xx		Policy Year 20xx		Prior Policy Year (20xx – 1 year)		Prior Policy Year (20xx – 2 years)		Prior Policy Year (20xx – 3 years)
Step Three Totals		Not Applicable	$		$		$		$
MULTIPLY BY Surcharge Percentage Established by Treasury for Individual Policy Years		Not Applicable		%		%		%		%
EQUALS Surcharge by Policy Year		Not Applicable	$		$		$		$

Total Surcharge for Year (add Columns 2 - 5):

$

6. Step Five:

Complete the following formula to determine the insurer’s Federal Terrorism Policy Surcharge due to Treasury for the applicable year.

Step Four Total Surcharge for Year	$
SUBTRACT Previously Reported and Remitted	$
EQUALS Surcharge Still Due to Treasury for the Calendar Year	$

6. Certification

I hereby certify that the Direct Written Premium data, calculations, and supporting documentation used to determine the insurer’s Federal Terrorism Policy Surcharge are accurate and complete to the best of my information, knowledge, and belief. Any false or fraudulent statements may subject the insurer or signatory to criminal, civil, and/or administrative penalties.

Name Officer Title Date

Signature

Notice under the Paperwork Reduction Act

We estimate it will take you about 5 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 https://tripclaims.treas.gov/TRIP/.

Page 8 OMB No. 1505-200 (Exp.: X/X/2020)

TRIP 04B