TRIP 01 Notice of Deductible Erosion

Control Number

(Treasury Use)

TERRORISM RISK INSURANCE PROGRAM

NOTICE OF DEDUCTIBLE EROSION

Pursuant to 31 CFR 50.72, this form must be submitted to Treasury when the incurred aggregate insured losses (including reserves for “incurred but not reported” losses) for an insurer, or collectively for a group of affiliated insurers, exceed an amount equal to 50 percent of the insurer’s deductible within a calendar year. One form should be submitted based on all insured losses applicable to a particular calendar year once there has been a Program Trigger Event¹ applicable to that calendar year. In order to receive payment of the Federal share of compensation, the insurer must register with the Terrorism Risk Insurance Program Claims Facility and also be registered in the Central Contractor Registration (CCR). Further information can be obtained online at https://tripclaims.treas.gov/TRIP/.

1. Insurer or Insurer Group Name: ________________________________

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

3. List all affiliated insurers with premium subject to Terrorism Risk Insurance Act:

Name		NAIC # (or TIN if no NAIC #)

(add more lines as needed)

4. Calendar Year: ________ E. ISO/PCS Catastrophe Code(s) _____ _____ _____

6. Estimated aggregate insured losses from Program Trigger event(s): $____________________

6. Estimated insurer deductible for Calendar Year: $________________________

• See Certification of Loss Schedule A for guidance, even if Schedule A is not being submitted at this time

6. Estimated Federal share of compensation: $_______________________

• Federal share percentage of insured losses (F) in excess of insurer deductible (G).

• For losses occurring in calendar year 2017, percentage of Federal share is 83% of insured losses (F) in excess of insurer deductible (G). For 2018, Federal share is 82%. For 2019, Federal share is 81%. For 2020, Federal share is 80%.

_________________________________

Program Trigger Event means a certified act of terrorism within a calendar year that results in aggregate industry insured losses, either on its own or in combination with any of certified act(s) of terrorism having taken place in the same calendar year, exceeding: $140 million (calendar year 2017); $160 million (calendar year 2018); $180 million (calendar year 2019); $200 million (calendar year 2020). See 31 CFR 50.4(v).

6. Provide the insurer’s point of contact for loss and compliance certifications and for payments of Federal share of compensation. In the case of affiliated insurers, a single insurance entity among the affiliated group must be designated to act as the single point of contact.

Contact’s Name:

Contact’s Title:

Insurer Name:

Mailing Address:

Telephone Number(s):

Fax Number(s):

E-mail Address:

6. (Optional) Schedule A “Declaration of Direct Earned Premium and Insurer Deductible” attached?

Yes No

6. Notice of Deductible Erosion submitted by:

Name: ________________________________

Title: ________________________________

Signature: ________________________________

Date: ________________________________

Notice under the Paperwork Reduction Act

We estimate it will take you about 60 minutes 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/.

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