TBD Terrorism Risk Insurance Program: Small Insurers

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Overview

Affiliations
Premium (Juris.)
Standalone Terrorism (US)
Cyber (US)
Exposure Bases (Juris.)
Reinsurance (US)
PRA Notice

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Sheet 1: Affiliations

	B	C				G	H
3	NAIC Group Code	Insurer Group Name			3	Total 2016 Policyholder Surplus
4					4	Total 2016 TRIP-Eligible DEP (all lines)
	B	C	D
8	NAIC Company Code	Insurance Company Name	Type of Insurer
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

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Sheet 2: Premium (Juris.)

	Jurisdiction:
2
	B	C	D	E	F	G	H
5	TRIP-Eligible Line of Coverage	NAIC Line (Commercial Only)	Total 2017 TRIP-Eligible DEP (all policies)	Total 2017 TRIP-Eligible DEP (Terrorism Risk Coverage Declined)	Total 2017 TRIP-Eligible DEP (Terrorism Risk Coverage Provided for Disclosed $0 Charge)	Total 2017 TRIP-Eligible DEP (Terrorism Risk Coverage Provided with a Premium Charged)	Total 2017 DEP Charged for Terrorism Risk Coverage
6	Fire	1	$-
7	Allied Lines	2.1	$-
8	Commercial Multiple Peril (non-liability portion)	5.1	$-
9	Commercial Multiple Peril (liability portion)	5.2	$-
10	Ocean Marine	8	$-
11	Inland Marine	9	$-
12	Workers' Compensation	16	$-
13	Excess Workers' Compensation	17.3	$-
14	Other Liability	17	$-
15	Products Liability	18	$-
16	Aircraft (all perils)	22	$-
17	Boiler and Machinery	27	$-
18	TOTALS		$-	$-	$-	$-	$-

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Sheet 3: Standalone Terrorism (US)

	B	C
2	Element	Amount
3	2017 DEP for Standalone Terrorism Policies
4	Portion of 2017 DEP Providing Coverage for Losses for Certified Acts of Terrorism under TRIP
5	Portion of 2017 DEP Providing Coverage for Losses Arising from Other (Non-Certified) Acts of Terrorism
6	2017 Number of Standalone Terrorism Policies Issued
7	2017 Number of Standalone Terrorism Policies Issued Providing Coverage for Losses for Certified Acts of Terrorism under TRIP
8	2017 Property Insurance Exposure for Standalone Terrorism Policies Providing Coverage for Losses for Certified Acts of Terrorism under TRIP
9	2017 Total Limits of Liability for Standalone Terrorism Policies Providing Coverage for Losses for Certified Acts of Terrorism under TRIP

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Sheet 4: Cyber (US)

	B	C	D	E
2	Element	Standalone Cyber	Cyber Coverage Provided as Part of a Package Policy	Totals
3	2017 TRIP-Eligible DEP for Cyber Policies
4	2017 TRIP-Eligible DEP for Cyber Policies (Terrorism Risk Coverage Declined)
5	2017 TRIP-Eligible DEP for Cyber Policies (Terrorism Risk Coverage Provided)
6	2017 Total Disclosed Terrorism Risk Coverage DEP Charged Under Cyber Policies
7	2017 Number of Cyber Policies Issued
8	2017 Number of Cyber Policies Issued (Terrorism Risk Coverage Provided)
9	2017 Total Liability Policy Limits for Cyber Policies (Terrorism Risk Coverage Provided)

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Sheet 5: Exposure Bases (Juris.)

	Jurisdiction:
2
	B	C	D	E	F	G	H	I	J	K	L
5	TRIP-Eligible Line of Coverage	NAIC Line (Commercial Only)	Total 2017 TRIP-Eligible Property Exposure (Terrorism Risk Coverage Provided)	Total 2017 Policyholder Deductibles for TRIP-Eligible Property Policies (Terrorism Risk Coverage Provided)	Total 2017 TRIP-Eligible Property Exposure (Terrorism Risk Coverage Declined)	Total 2017 Policyholder Deductibles for TRIP-Eligible Property Policies (Terrorism Risk Coverage Declined)	Total 2017 TRIP-Eligible Liability Exposure (Terrorism Risk Coverage Provided)	Total 2017 Policyholder Deductibles for TRIP-Eligible Liability Policies (Terrorism Risk Coverage Provided)	Total 2017 TRIP-Eligible Liability Exposure (Terrorism Risk Coverage Declined)	Total 2017 Policyholder Deductibles for TRIP-Eligible Liability Policies (Terrorism Risk Coverage Declined)	Total 2017 Payroll for TRIP-Eligible Policies (Terrorism Risk Coverage Provided)
6	Fire	1
7	Allied Lines	2.1
8	Commercial Multiple Peril (non-liability portion)	5.1
9	Commercial Multiple Peril (liability portion)	5.2
10	Ocean Marine	8
11	Inland Marine	9
12	Workers' Compensation	16
13	Excess Workers' Compensation	17.3
14	Other Liability	17
15	Products Liability	18
16	Aircraft (all perils)	22
17	Boiler and Machinery	27
18	TOTALS		$-	$-	$-	$-	$-	$-	$-	$-	$-

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Sheet 6: Reinsurance (US)

	B	C	D
2	Element	Response	Description or Explanation (if any)
3	Size of TRIP 2017 Deductible (Cell H4 of Insurer Group Affiliations Chart x 20%)
4	Total 2017 Limits Any One Loss of Purchased Treaty Reinsurance Covering TRIP Loss
5	Total 2017 Aggregate Limits of Purchased Treaty Reinsurance Covering TRIP Loss
6	2017 Attachment Point of Purchased Treaty Reinsurance Covering TRIP Loss
7	2017 Co-Participation Share of Purchased Treaty Reinsurance Covering TRIP Loss
8	Total 2017 Limits Any One Loss of Purchased Treaty Reinsurance Covering Natural Catastrophe Loss
9	Total 2017 Aggregate Limits of Purchased Treaty Reinsurance Covering Natural Catastrophe Loss
10	2017 Attachment Point of Purchased Treaty Reinsurance Covering Natural Catastrophe Loss
11	2017 Co-Participation Share of Purchased Treaty Reinsurance Covering Natural Catastrophe 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, Total 2017 Limits of NBCR Reinsurance for Certified Acts of Terrorism involving WC Loss
16	If Yes, 2017 Attachment Point of NBCR Reinsurance for Certified Acts of Terrorism involving WC Loss
17	If Yes, 2017 Co-Participation Share (if any) 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, Total 2017 Limits of NBCR Reinsurance for Certified Acts of Terrorism involving Property Loss
20	If Yes, 2017 Attachment Point of NBCR Reinsurance for Certified Acts of Terrorism involving Property Loss
21	If Yes, 2017 Co-Participation Share (if any) 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, Total 2017 Limits of NBCR Reinsurance for Certified Acts of Terrorism involving Liability Loss
24	If Yes, 2017 Attachment Point of NBCR Reinsurance for Certified Acts of Terrorism involving Liability Loss
25	If Yes, 2017 Co-Participation Share (if any) of NBCR Reinsurance for Certified Acts of Terrorism involving Liability Loss
26	Any other reinsurance exclusions specifically applicable to TRIP Certified Acts of Terrorism?
27	ZIP Code Associated with Largest Progably Maximum Loss (PML)
28	Largest PML at a Single Location (Amount)

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Sheet 7: PRA Notice

Notice under the Paperwork Reduction Act

We estimate it will take you about 25 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.