TRIP 04A Direct Written Premium and Monthly Surcharge Calculation

C ontrol Number

(Treasury use)

TERRORISM RISK INSURANCE PROGRAM

DIRECT WRITTEN PREMIUM AND MONTHLY SURCHARGE CALCULATION

1. Insurer Name:

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

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

5. Type of submission: Original Correction

6. Step One A:

Enter the insurer’s Direct Written Premium through the applicable month for commercial lines of business (see instructions for guidance) 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. Column 1A is always cumulative for the applicable calendar year during an assessment period, and Column 1B is the Direct Written Premium for the same calendar year prior to the start of the assessment period. Columns 1B and 1C must sum to equal Column 1A. All entries should be provided in whole dollars.

	- Column 1A -		- Column 1B -		- Column 1C -
	Cumulative Premium Year to Date		Premium Prior to Assessment Period		Cumulative Premium During Assessment Period
$		$		$

5. 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. See instructions for guidance. All entries should be provided in whole dollars.

		- Column 1C -		- Column 2 -				- Column 3 -				- Column 4 -				- Column 5 -
		Cumulative Premium During Assessment Period			Policy Year 20xx				Prior Policy Year (20xx – 1 year)				Prior Policy Year (20xx – 2 years)				Prior Policy Year (20xx – 3 years)
STEP ONE TOTALS:	$		$			$				$				$

5. Step Two:

Enter total premium, if any, included in the Direct Written Premium reported under Step One Totals (calculated in Step One B) that is for insurance coverage not subject to the Federal Terrorism Policy Surcharge (see instructions for guidance)

		- Column 1C -		- Column 2 -				- Column 3 -				- Column 4 -				- Column 5 -
		Cumulative Premium During Assessment Period			Policy Year 20xx				Prior Policy Year (20xx – 1 year)				Prior Policy Year (20xx – 2 years)				Prior Policy Year (20xx – 3 years)
STEP TWO TOTALS:	$		$			$				$				$

5. 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 -
		Cumulative Premium During Assessment Period		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	$		$		$		$		$

5. Step Four:

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

		- 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)
Premium Subject to Surcharge (Step Three)		Not Applicable	$		$		$		$
MULTIPLY BY Surcharge Percentage Established by Treasury for Individual Policy Years		Not Applicable		%		%		%		%
EQUALS Surcharge by Policy Year		Not Applicable	$		$		$		$

Cumulative Total Due (add Surcharge by Policy Year Columns 2 - 5):

$

5. Step Five:

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

Step Four Cumulative Total Due	$
SUBTRACT Amount Previously Remitted	$
EQUALS Surcharge Amount Due	$

5. 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 5 OMB No. 1505-1505 (Exp.: X/X/2020)

TRIP 04A