| B | C | G | H | |||||
| 3 | Group Code (NAIC or as assigned by Aggregator) | Insurer Group Name | 3 | Total 2020 Policyholder Surplus: | ||||
| 4 | 4 | Total 2020 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 2021 TRIP-Eligible DEP (all policies) | Total 2021 TRIP-Eligible DEP (Terrorism Risk Coverage Declined) | Total 2021 TRIP-Eligible DEP (Terrorism Risk Coverage Provided for Disclosed $0 Charge) | Total 2021 TRIP-Eligible DEP (Terrorism Risk Coverage Provided with a Premium Charged) | Total 2021 DEP Charged for Terrorism Risk Coverage |
| 6 | Fire | 1 | $- | ||||
| 7 | Fire Deductible Reimbursement | 1 | $- | ||||
| 8 | Allied Lines | 2.1 | $- | ||||
| 9 | Allied Lines Deductible Reimbursement | 2.1 | $- | ||||
| 10 | Commercial Multiple Peril (non-liability portion) | 5.1 | $- | ||||
| 11 | Commercial Multiple Peril (non-liability portion) Deductible Reimbursement | 5.1 | $- | ||||
| 12 | Commercial Multiple Peril (liability portion) | 5.2 | $- | ||||
| 13 | Commercial Multiple Peril (liablity portion) Deductible Reimbursement | 5.2 | $- | ||||
| 14 | Ocean Marine | 8 | $- | ||||
| 15 | Ocean Marine Deductible Reimbursement | 8 | |||||
| 16 | Inland Marine | 9 | $- | ||||
| 17 | Inland Marine Deductible Reimbursement | 9 | |||||
| 18 | Workers' Compensation | 16 | $- | ||||
| 19 | Workers' Compensation Deductible Reimbursement | 16 | $- | ||||
| 20 | Excess Workers' Compensation | 17.3 | $- | ||||
| 21 | Other Liability | 17 | $- | ||||
| 22 | Other Liablity Deductible Reimbursement | 17 | $- | ||||
| 23 | Products Liability | 18 | $- | ||||
| 24 | Products Liablity Deductible Reimbursement | 18 | $- | ||||
| 25 | Aircraft (all perils) | 22 | $- | ||||
| 26 | Aircraft (all perils) Deductible Reimbursement | 22 | $- | ||||
| 27 | Boiler and Machinery | 27 | $- | ||||
| 28 | Boiler and Machinery Deductible Reimbursement | 27 | $- | ||||
| 29 | TOTALS | $- | $- | $- | $- | $- | |
| 30 | Total 2021 Non-TRIP Eligible Lines DEP | ||||||
| B | C | |
| 2 | Element | Amount |
| 3 | 2021 DEP for Standalone Terrorism Policies | |
| 4 | Portion of 2021 DEP Providing Coverage for Losses for Certified Acts of Terrorism under TRIP | |
| 5 | Portion of 2021 DEP Providing Coverage for Losses Arising from Other (Non-Certified) Acts of Terrorism | |
| 6 | 2021 Number of Standalone Terrorism Policies Issued | |
| 7 | 2021 Number of Standalone Terrorism Policies Issued Providing Coverage for Losses for Certified Acts of Terrorism under TRIP | |
| 8 | 2021 Property Insurance Exposure for Standalone Terrorism Policies Providing Coverage for Losses for Certified Acts of Terrorism under TRIP | |
| 9 | Total 2021 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 | Total 2021 TRIP-Eligible DEP (All Cyber Policies) | $- | ||
| 4 | Total 2021 Cyber DEP in TRIP-Eligible Lines of Insurance (Terrorism Risk Coverage Declined) | $- | ||
| 5 | Total 2021 Cyber DEP in TRIP-Eligible Lines of Insurance (Terrorism Risk Coverage Provided) | $- | ||
| 6 | Total 2021 TRIP-Eligible DEP Charged for Terrorism Risk Coverage Under Cyber Policies | $- | ||
| 7 | Total 2021 Non-TRIP-Eligible DEP (All Cyber Policies) | $- | ||
| 8 | Total 2021 Number of Cyber Policies Issued in TRIP-Eligible Lines of Insurance | 0 | ||
| 9 | Total 2021 Number of Cyber Policies Issued (Terrorism Risk Coverage Provided) | 0 | ||
| 10 | Total 2021 Number of Cyber Policies Issued in Non-TRIP-Eligible Lines of Insurance | 0 | ||
| 11 | Total 2021 Number of all Cyber Policies Issued | 0 | ||
| 12 | Total 2021 Number of all Cyber Policies Issued to Small Policyholders (100 or fewer employees) | 0 | ||
| 13 | Total 2021 Number of all Cyber Policies Issued to Medium Policyholders (101-500 employees) | 0 | ||
| 14 | Total 2021 Number of all Cyber Policies Issued to Large Policyholders (501 or more employees) | 0 | ||
| 15 | Total 2021 DEP of all Cyber Policies Issued to Small Policyholders (100 or fewer employees) | $- | ||
| 16 | Total 2021 DEP of all Cyber Policies Issued to Medium Policyholders (101-500 employees) | $- | ||
| 17 | Total 2021 DEP of all Cyber Policies Issued to Small Policyholders (501 or more employees) | $- | ||
| 18 | Total 2021 Limits of Liability for Cyber Policies Issued in TRIP-Eligible Lines of Insurance | $- | ||
| 19 | Total 2021 Limits of Liability for Cyber Policies Issued in TRIP-Eligible Lines of Insurance Providing Coverage for Losses for Certified Acts of Terrorism Under TRIP | $- | ||
| 20 | Total 2021 Limits of Liability for Cyber Policies Issued in Non-TRIP-Eligible Lines of Insurance | $- | ||
| 21 | Total 2021 Limits of Liability for Cyber Extortion under Cyber Policies Issued in TRIP-Eligible Lines of Insurance | $- | ||
| 22 | Total 2021 Limits of Liability for Ransom Payments for Cyber Extortion under Cyber Policies Issued in TRIP-Eligible Lines of Insurance | $- | ||
| 23 | Total 2021 Limits of Liability for Cyber Extortion under Cyber Policies Issued in Non-TRIP-Eligible Lines of Insurance | $- | ||
| 24 | Total 2021 Limits of Liability for Ransom Payments for Cyber Extortion under Cyber Policies Issued in Non-TRIP-Eligible Lines of Insurance | $- | ||
| 25 | Total 2021 Direct Losses Paid for Cyber Extortion under all Cyber Policies Issued | $- | ||
| 26 | Total 2021 Direct Losses Incurred for Cyber Extortion under all Cyber Policies Issued | $- | ||
| 27 | Total 2021 Direct Losses Paid for Cyber Extortion (Ransom Payment or Reimbursement Only) under all Cyber Policies Issued | $- | ||
| 28 | Total 2021 Number of Claims Associated with Payments reported in Line 27 | 0 | ||
| 29 | Total 2021 Direct Defense and Loss Containment Amounts Paid for Cyber Extortion under all Cyber Policies Issued | $- | ||
| 30 | Total 2021 Direct Defense and Loss Containment Amounts Incurred for Cyber Extortion under all Cyber Policies Issued | $- | ||
| Jurisdiction: | ||||||||||||||||
| 2 | ||||||||||||||||
| B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | |
| 5 | TRIP-Eligible Line of Coverage | NAIC Line (Commercial Only) | Total 2021 TRIP-Eligible Property Exposure (Terrorism Risk Coverage Provided) | Total 2021 TRIP-Eligible Property Exposure (Terrorism Risk Coverage Provided and NBCR Risks Not Excluded) | Total 2021 TRIP-Eligible Property Exposures (Terrorism Risk Coverage Provided Only for NBCR Risks) | Total 2021 Policyholder Deductibles for TRIP-Eligible Property Policies (Terrorism Risk Coverage Provided) | Total 2021 TRIP-Eligible Property Exposure (Terrorism Risk Coverage Declined) | Total 2021 Policyholder Deductibles for TRIP-Eligible Property Policies (Terrorism Risk Coverage Declined) | Total 2021 Limits of Liability for TRIP-Eligible Policies (Terrorism Risk Coverage Provided) | Total 2021 TRIP-Eligible Limits of Liability (Terrorism Risk Coverage Provided and NBCR Risks Not Excluded) | Total 2021 TRIP-Eligible Limits of Liability (Terrorism Risk Coverage Provided Only for NBCR Risks) | Total 2021 Policyholder Deductibles for TRIP-Eligible Liability Policies (Terrorism Risk Coverage Provided) | Total 2021 Limits of Liability for TRIP-Eligible Liability Policies (Terrorism Risk Coverage Declined) | Total 2021 Policyholder Deductibles for TRIP-Eligible Liability Policies (Terrorism Risk Coverage Declined) | Total 2021 Payroll for TRIP-Eligible Policies (Terrorism Risk Coverage Provided) | Total 2021 Payroll Not Subject to Terrorism Risk Coverage |
| 6 | Fire | 1 | ||||||||||||||
| 7 | Fire Deductible Reimbursement | 1 | ||||||||||||||
| 8 | Allied Lines | 2.1 | ||||||||||||||
| 9 | Allied Lines Deductible Reimbursement | 2.1 | ||||||||||||||
| 10 | Commercial Multiple Peril (non-liability portion) | 5.1 | ||||||||||||||
| 11 | Commercial Multiple Peril (non-liability portion) Deductible Reimbursement | 5.1 | ||||||||||||||
| 12 | Commercial Multiple Peril (liability portion) | 5.2 | ||||||||||||||
| 13 | Commercial Multiple Peril (liability portion) Deductible Reimbursement | 5.2 | ||||||||||||||
| 14 | Ocean Marine | 8 | ||||||||||||||
| 15 | Ocean Marine Deductible Reimbursement | 8 | ||||||||||||||
| 16 | Inland Marine | 9 | ||||||||||||||
| 17 | Inland Marine Deductible Reimbursement | 9 | ||||||||||||||
| 18 | Workers' Compensation | 16 | ||||||||||||||
| 19 | Workers' Compensation Deductible Reimbursement | 16 | ||||||||||||||
| 20 | Excess Workers' Compensation | 17.3 | ||||||||||||||
| 21 | Other Liability | 17 | ||||||||||||||
| 22 | Other Liability Deductible Reimbursement | 17 | ||||||||||||||
| 23 | Products Liability | 18 | ||||||||||||||
| 24 | Products Liability Deductible Reimbursement | 18 | ||||||||||||||
| 25 | Aircraft (all perils) | 22 | ||||||||||||||
| 26 | Aircraft (all perils) Deductible Reimbursement | 22 | ||||||||||||||
| 27 | Boiler and Machinery | 27 | ||||||||||||||
| 28 | Boiler and Machinery Deductible Reimbursement | 27 | ||||||||||||||
| 29 | TOTALS | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||
| A | B | |
| 2 | NAICS Code Number Most Applicable to the Business(es) Insured by the Captive Insurer: | |
| C | D | E | F | G | H | I | J | K | L | M | N | O | ||
| Property | Liability | Workers' Compensation | All Categories | |||||||||||
| 3 | Code | Description | Total 2021 DEP Charged for Terrorism Risk Coverage | Total 2021 TRIP-Eligible DEP (Terrorism Risk Coverage Declined) | Total 2021 TRIP-Eligible DEP (Terrorism Risk Coverage Provided) | Total 2021 TRIP-Eligible DEP | Total 2021 DEP Charged for Terrorism Risk Coverage | Total 2021 TRIP-Eligible DEP (Terrorism Risk Coverage Declined) | Total 2021 TRIP-Eligible DEP (Terrorism Risk Coverage Provided) | Total 2021 TRIP-Eligible DEP | Total 2021 DEP Charged for Terrorism Risk Coverage | Total 2021 TRIP-Eligible DEP | Total 2021 TRIP-Eligible DEP | |
| 4 | NAICS | 813110 | Religious Organizations | $- | $- | $- | ||||||||
| 5 | SIC | 8661 | Religious Organizations | $- | $- | $- | ||||||||
| 6 | ISO | 0900 (Property) 41650 (Liablity) |
Religious Organizations | $- | $- | $- | ||||||||
| 7 | Other | Places of Worship | $- | $- | $- | |||||||||
| 8 | TOTALS: | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| B | C | D | E | F | G | |
| 2 | Region | Description | Total 2021 Payroll for TRIP-Eligible Primary WC and Excess WC Policies (Terrorism Risk Coverage Provided) | Total 2021 Payroll for TRIP-Eligible Primary WC and Excess WC Policies (Terrorism Risk Coverage Not Provided) | Total 2021 TRIP-Eligible Property Exposure (Terrorism Risk Coverage Provided) | Total 2021 TRIP-Eligible Property 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 2021 Deductible (Cell H4 of Insurer Group Affiliations Chart x 20%) | |||
| 4 | Total 2021 Limits Any One Loss of Purchased Treaty Reinsurance Covering TRIP Loss | |||
| 5 | Total 2021 Aggregate Limits of Purchased Treaty Reinsurance Covering TRIP Loss | |||
| 6 | 2021 Attachment Point Any One Loss of Purchased Treaty Reinsurance Covering TRIP Loss | |||
| 7 | 2021 Co-Participation Share Any One Loss of Purchased Treaty Reinsurance Covering TRIP Loss | |||
| 8 | Total 2021 Limits Any One Loss of Purchased Treaty Reinsurance Covering Natural Catastrophic Loss | |||
| 9 | Total 2021 Aggregate Limits of Purchased Treaty Reinsurance Covering Natural Catastrophic Loss | |||
| 10 | 2021 Attachment Point Any One Loss of Purchased Treaty Reinsurance Covering Natural Catastrophic Loss | |||
| 11 | 2021 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, 2021 Limits Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving WC Loss | |||
| 16 | If Yes, 2021 Attachment Point Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving WC Loss | |||
| 17 | If Yes, 2021 Co-Participation Share (if any) Any One Loss 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, 2021 Limits Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving Property Loss | |||
| 20 | If Yes, 2021 Attachment Point Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving Property Loss | |||
| 21 | If Yes, 2021 Co-Participation Share (if any) Any One Loss 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, 2021 Limits Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving Liability Loss | |||
| 24 | If Yes, 2021 Attachment Point Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving Liability Loss | |||
| 25 | If Yes, 2021 Co-Participation Share (if any) Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving Liability Loss | |||
| 26 | Any Other Reinsurance Exclusions Specifically Applicable to Certified Acts of Terrorism Under TRIP? | |||
| 27 | Using the following defined terrorism event, calculate and report the total projected loss under property, workers' compensation, and liability 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. On October 13, 2021 (a Wednesday), at 11:00 a.m. (Eastern Time), a 5 to 6 ton truck bomb is detonated in downtown Miami, Florida, on Biscayne Boulevard Way, between Brickell Avenue and SE Third Avenue. The precise GPS coordinates are 25° 46’ 15” N, 80° 11’ 22” W. 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). In addition, for purposes of estimating any workers’ compensation impacts, do not modify your estimates based upon any projections or assumptions as to a reduced number of employees in the affected area based upon the impacts of the COVID-19 pandemic. Rather, assume the area contains the number of employees (consistent with the estimates provided below) that would be expected to be in the area without accounting for any potential reductions on account of COVID-19. -Zone 1 (less than 100 meters from site): Collapse and fire following, 100% property damage, 10% fire loss -Zone 2 (100-200 meters from site): Massive structural damage to surrounding properties, 50% property damage, 5% fire loss -Zone 3 (200-400 meters from site): Heavy debris damage to surrounding properties, 25% property damage, 2.5% fire loss -Zone 4 (400-500 meters from site): Light debris damage to surrounding properties, 10% property damage, 1% fire loss Radius of potential damage: Up to 1600 meters. Between 500-1600 meters you may assume 1% property damage and 0% fire loss. -Worker Injuries: 1,500 blue/white collar deaths in total and 3,000 injuries in total. The following further assumptions can be applied as to the level of injuries incurred among workers: 20 percent permanent total disability; 30 percent permanent partial disability; and 50 percent temporary disability. |
|||
| 30 | Total Projected Loss | $- | ||
| 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 | |||
| Notice under the Paperwork Reduction Act We estimate it will take you about 52 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 |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |