TRIP 07 Monthly Claims Report

Control Number:

(Treasury use)

TERRORISM RISK INSURANCE PROGRAM

MONTHLY CLAIMS REPORT

Insurer or Insurer Group Name:

NAIC Insurer (or Group) Number:

TIN (if no NAIC #):

Month:

Calendar Year:

Data as of:

Field #:

1

2

3

4

5

6

7

8

9

10

11

12

CAT CODE

LINE OF BUSINESS CODE

LOC OF LOSS STATE CD

DATE OF LOSS

INSURER NUMBER

INSURER NAME

CLAIM #

INSURED NAME

LOSS PAID AMOUNT

ALAE PAID

TOTAL CURRENT LOSS AMOUNT

RESERVES

0.00

0.00

0.00

0.00

0.00

0.00

0.00

Totals:

NA

NA

NA

NA

NA

NA

NA

NA

0.00

0.00

0.00

0.00

Instruction to add more lines

As this spreadsheet has been constructed with formulae for data fields that need to be totaled, please insert any additional data records (rows) before (above) the “Totals” row.

Notice under the Paperwork Reduction Act We estimate it will take you about 2 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.