TRIP 04B Direct Written Premium and Federal Terrorism Policy Surc

Control No. ____________

(Treasury use)

TERRORISM RISK INSURANCE PROGRAM

STATEMENT OF “DIRECT WRITTEN PREMIUM” AND END OF YEAR

CALCULATION OF “FEDERAL TERRORISM POLICY SURCHARGE” DUE UNDER

TERRORISM RISK INSURANCE ACT (TRIA)

Insurer Name: ___________________________________________________________

NAIC Insurer Number (or TIN if no NAIC #): __________

Calendar Year of Direct Written Premium (see instructions for guidance): ___________

Submitted for Period Ending: ____________________ Is this submission an original or a correction? (enter an ‘O’ or ‘C’): _____

Step One A:

Enter direct Written Premiums for commercial lines of business (listed below) as 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. Columns 1B and 1C should sum to 1A.

Annual Statement Line of Business	- Column 1A- Premium Reported on Statutory Page 14 or Equivalent Calendar Year 20xx	- Column 1B - Premium Prior to Assessment Period Calendar Year 20xx (if applicable)	- Column 1C - Premium During Assessment Period Calendar Year 20xx
Line 1 – Fire	$___________________	$__________________	$__________________
Line 2.1 – Allied Lines	$___________________	$__________________	$__________________
Line 5.1 – Commercial Multiple Peril (non-liability portion)	$___________________	$__________________	$__________________
Line 5.2 – Commercial Multiple Peril (liability portion)	$___________________	$__________________	$__________________
Line 8 – Ocean Marine	$___________________	$__________________	$__________________
Line 9 – Inland Marine	$___________________	$__________________	$__________________
Line 16 – Workers’ Compensation	$___________________	$__________________	$__________________
Line 17 – Other Liability	$___________________	$__________________	$__________________
Line 18 – Products Liability	$___________________	$__________________	$__________________
Line 22 – Aircraft (all perils)	$___________________	$__________________	$__________________
Line 27 – Boiler and Machinery	$___________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________
(insurers may add more lines as needed)

Step One B:

Enter direct Written Premiums for commercial lines of business (listed below) as reported in column 1C in Step 1A. Columns 2 – 5 should sum to Column 1C. However, if necessary, additional columns (and sheets) may be added to complete the breakout of premiums by Policy Year and to account fully for the entry in Column 1C. See instructions for guidance. Note, all entries are in whole dollars.

	Direct Written Premium
Annual Statement Line of Business	- Column 1C - Premium During Assessment Period Calendar Year 20xx	- Column 2 - Policy Year 20xx	- Column 3 - Prior Policy Year (20xx -1 year)	- Column 4 - Prior Policy Year (20xx -2 years)	- Column 5 - Prior Policy Year (20xx -3 years)
Line 1 – Fire	$___________________	$__________________	$__________________	$__________________	$__________________
Line 2.1 – Allied Lines	$___________________	$__________________	$__________________	$__________________	$__________________
Line 5.1 – Commercial Multiple Peril (non-liability portion)	$___________________	$__________________	$__________________	$__________________	$__________________
Line 5.2 – Commercial Multiple Peril (liability portion)	$___________________	$__________________	$__________________	$__________________	$__________________
Line 8 – Ocean Marine	$___________________	$__________________	$__________________	$__________________	$__________________
Line 9 – Inland Marine	$___________________	$__________________	$__________________	$__________________	$__________________
Line 16 – Workers’ Compensation	$___________________	$__________________	$__________________	$__________________	$__________________
Line 17 – Other Liability	$___________________	$__________________	$__________________	$__________________	$__________________
Line 18 – Products Liability	$___________________	$__________________	$__________________	$__________________	$__________________
Line 22 – Aircraft (all perils)	$___________________	$__________________	$__________________	$__________________	$__________________
Line 27 – Boiler and Machinery	$___________________	$__________________	$__________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________	$__________________	$__________________
(insurers may add more lines as needed)
STEP 1 TOTALS	$___________________	$__________________	$__________________	$__________________	$__________________

Step Two:

Enter premiums included in the direct written premium numbers reported in column 1C under STEP 1B that are for insurance coverage not subject to the Federal Terrorism Policy Surcharges (see instructions for guidance). Columns 2 – 5 should sum to column 1C. However, if necessary, additional columns (and sheets) may be added to complete the breakout of premiums by Policy Year and to account fully for the entry in Column 1C. See instructions for guidance. Note, all entries are in whole dollars.

	Direct Written Premium
Annual Statement Line of Business	- Column 1C - Premium During Assessment Period Calendar Year 20xx	- Column 2 - Policy Year 20xx	- Column 3 - Prior Policy Year (20xx -1 year)	- Column 4 - Prior Policy Year (20xx -2 years)	- Column 5 - Prior Policy Year (20xx -3 years)
Line 1 – Fire	$___________________	$__________________	$__________________	$__________________	$__________________
Line 2.1 – Allied Lines	$___________________	$__________________	$__________________	$__________________	$__________________
Line 5.1 – Commercial Multiple Peril (non-liability portion)	$___________________	$__________________	$__________________	$__________________	$__________________
Line 5.2 – Commercial Multiple Peril (liability portion)	$___________________	$__________________	$__________________	$__________________	$__________________
Line 8 – Ocean Marine	$___________________	$__________________	$__________________	$__________________	$__________________
Line 9 – Inland Marine	$___________________	$__________________	$__________________	$__________________	$__________________
Line 16 – Workers’ Compensation	$___________________	$__________________	$__________________	$__________________	$__________________
Line 17 – Other Liability	$___________________	$__________________	$__________________	$__________________	$__________________
Line 18 – Products Liability	$___________________	$__________________	$__________________	$__________________	$__________________
Line 22 – Aircraft (all perils)	$___________________	$__________________	$__________________	$__________________	$__________________
Line 27 – Boiler and Machinery	$___________________	$__________________	$__________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________	$__________________	$__________________
_______________________________	$___________________	$__________________	$__________________	$__________________	$__________________
(insurers may add more lines as needed)
STEP 2 TOTALS	$___________________	$__________________	$__________________	$__________________	$__________________

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.

	Direct Written Premium
	- Column 1C - Premium During Assessment Period Calendar Year 20xx	- Column 2 - Policy Year 20xx	- Column 3 - Prior Policy Year (20xx -1 year)	- Column 4 - Prior Policy Year (20xx -2 years)	- Column 5 - Prior Policy Year (20xx -3 years)
STEP 1B Totals (as applicable)	$___________________	$__________________	$__________________	$__________________	$__________________
SUBTRACT STEP 2 Totals (as applicable)	$___________________	$__________________	$__________________	$__________________	$__________________
EQUALS - Premium Subject to Surcharge	$___________________	$__________________	$__________________	$__________________	$__________________

Step Four:

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

	Direct Written Premium Subject to Surcharge
	- Column 1C -	- Column 2 - Policy Year 20xx	- Column 3 - Prior Policy Year (20xx -1 year)	- Column 4 - Prior Policy Year (20xx -2 years)	- Column 5 - Prior Policy Year (20xx -3 years)
Enter STEP3 Totals	Not Applicable	$__________________	$__________________	$__________________	$__________________
MULTIPLY by Surcharge Percentage Established by Treasury for Individual Policy Years		______%	______%	______%	______%
EQUALS Surcharge by Policy Year	Not Applicable	$__________________	$__________________	$__________________	$__________________
TOTAL Surcharge for Year (Add columns 2-5)	$__________________

Step Five:

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

STEP 4 TOTAL Surcharge for Year $___________________

SUBTRACT Previously Reported and Remitted $­­­­­­­­­­­­­­­­­­­­­­­­___________________

EQUALS Surcharge still due to Treasury for the calendar year $___________________

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, 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 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, 1425 New York Avenue, NW, Washington, DC 20220. Do not send completed form to this address. Submit forms according to instructions provided at www.treas.gov/trip.

OMB No. 1505-0207 Expiration: November 30, 2015

TRIP 04B (6/2012)