TRIP 02 Certification of Loss

Control Number

(Treasury use)

TERRORISM RISK INSURANCE PROGRAM

CERTIFICATION OF LOSS

Pursuant to 31 CFR 50.73, this form is to be used by insurers claiming the Federal share of compensation under the Terrorism Risk Insurance Program for insured losses arising from Program Trigger Events. The initial, and if necessary, supplemental, Certification(s) of Loss are to include data relevant to all insured losses paid or that will be paid as specified in 31 CFR 50.73(b)(2)(i) based on all Program Trigger Events within a Calendar Year. Schedules A, B, and C (see below) are required supporting documentation for this Certification of Loss form. Treasury must receive, or have received, a Notice of Deductible Erosion for the relevant Calendar Year in order to process a Certification of Loss. 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 via the internet at https://tripclaims.treas.gov.

1. Insurer or Insurer Group Name:

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

3. Certification: Initial or Supplementary D. Calendar Year of Event:

5. Data as of: / /

6. ISO/PCS Cat Code(s) ________ _________ _________ ________

7. Calculation of Federal Share of Compensation Claimed (*amounts from Bordereau):

Total Cumulative Losses Paid and To be Paid*	$
Plus Total Allocated Loss Adjustment Expenses Paid*	$
Less Punitive Damage Amounts Paid*	$
Subtotal Insured Losses Paid	$
Less Total Salvage and Subrogation Recovered*	$
Subtotal Adjusted Insured Losses Paid	$
Less Insurer Deductible (from TRIP 02A Schedule A)	$
Subtotal Excess of Deductible	$
Gross Federal Share ( __% of subtotal Excess of Deductible)1	$
Less Excess Insurer Recoveries (see 21 below)	$
Less Duplicate Federal Recoveries*	$
Total Net Federal Share of Compensation	$
Less Prior Claimed Federal Share of Compensation	$
Federal Share of Compensation due Insurer (due Treasury)2	$

¹For losses occurring in calendar year 2017, percentage of Federal share is 83% of insured losses. For 2018, Federal share is 82%. For 2019, Federal share is 81%. For 2020, Federal share is 80%.

²When the insurer is required to reimburse Treasury, payment may be remitted by check or wire transfer. Checks should be made payable to U.S. Treasury and addressed to Department of the Treasury, Office of Financial Management, Attn: 1722 I Street, NW, 7^th Floor, 1500 Pennsylvania Avenue, NW, Washington, DC 20220. Wire transfers should be made to ABA Number 021030004, Account Number 20010001. Please provide a brief description/identification number in the comments area.

5. Calculation of Excess Insurer Recoveries (if required):

Total Reinsurance Recoveries from Insured Losses	$ _____________________
Less Recoveries Repaid or to be Repaid to Reinsurers	$ _____________________
Subtotal Net Reinsurance Recoveries	$ _____________________
Plus Gross Federal Share (Line 9)	$ _____________________
Subtotal Total Insurer Recoveries	$ _____________________
Less Adjusted Insured Losses Paid (Line 6)	$ _____________________
Total Excess Insurer Recoveries (if less than zero, enter zero above)	$ _____________________

5. Supporting Schedules Attached (check all that apply):

Schedule A: Declaration of Direct Earned Premium and Insurer Deductible (Required unless already submitted with Notice of Deductible Erosion)

Schedule B: Certification of Compliance (Required)

Schedule C: Loss Bordereau (Required)

5. Certification

I hereby certify that the statements, data, calculations, and supporting documentation used to determine the Total Federal Share of Compensation claimed herein are accurate and complete to the best of my information, knowledge, and belief. Any false or fraudulent statements or claims may subject the insurer and 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 90 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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