Form TRIP 04A TRIP 04A DIRECT WRITTEN PREMIUM AND MONTHLY SURCHARGE CALCULATION

Control Number_____________________

(Treasury use)

TERRORISM RISK INSURANCE PROGRAM

STATEMENT OF “DIRECT WRITTEN PREMIUM”

AND

MONTHLY 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): ___________ Reporting Month: ________________

Is this submission an original or a correction? (enter an ‘O’ or ‘C’): _____

Step One:

Enter the direct Written Premiums 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 Column 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
	-Column 1A- Cumulative Premium Year to Date	-Column 1B- Premium Prior to Assessment Period	- Column 1C - Cumulative Premium During Assessment Period	- 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 Two:

Enter premiums, if any, included in the direct written premium reported under STEP 1 that are for insurance coverage not subject to the Federal Terrorism Policy Surcharges (see instructions for guidance).

	Direct Written Premium
	- Column 1C - Cumulative Premium During Assessment Period	- 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 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 – Cumulative Premium During Assessment Period	- 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 1 Numbers (as applicable)	$________________	$________________	$________________	$________________	$________________
SUBTRACT STEP 2 Numbers (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 period.

	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)
Premium Subject to Surcharge (Step 3)	$______________	$________________	$________________	$________________		$______________
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) $_______________________
AMOUNT PREVIOUSLY REMITTED $_______________________
SURCHARGE AMOUNT DUE $_______________________

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 04A (6/2012)