TRIP 02B Schedule B

C ontrol Number

(Treasury Use)

TERRORISM RISK INSURANCE PROGRAM

SCHEDULE B

CERTIFICATION OF COMPLIANCE WITH SECTION 103(b)

OF TERRORISM RISK INSURANCE ACT (TRIA)

1. Insurer or Insurer Group Name:

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

3. If insurer is residual market mechanism allocating losses, enter loss allocation date:

4. Calendar Year of Event:

5. Certification:

I hereby certify that to the best of my information, knowledge and belief:

1. For each insurer with underlying losses included with this Certification of Loss:

1. The insurer has either: (a) paid all underlying claims comprising the insured losses listed in the Bordereau (Schedule C) provided, pursuant to 31 CFR 50.73(b)(1); or (b) will pay such underlying claims upon receipt of an advance payment of the Federal share of compensation, consistent with the insurer’s normal business practices, but not longer than five business days after receipt of the Federal share of compensation;

2. The underlying claims for insured losses were filed by persons who suffered an insured loss, or by persons acting on behalf of such persons;

3. The underlying claims for insured losses were processed in accordance with appropriate business practices and the procedures specified in 31 CFR Part 50 Subpart H;

4. The insurer has provided clear and conspicuous disclosure to the policyholder of the premium charged for insured losses covered by the Program and the Federal share of compensation for insured losses under the Program for each underlying insured loss that is included in the amount of the insurer’s aggregate insured losses, by complying with the disclosure requirements of 31 CFR 50.10 through 50.17;

5. The insurer has provided a clear and conspicuous disclosure to the policyholder, at the time of offer, purchase, and renewal of the policy, regarding the existence of the $100 billion cap on payments for insured losses under Section 103(e)(2) of TRIA, for each underlying insured loss that is included in the amount of the insurer’s aggregate insured losses; and

6. The insurer has made available, in all of its commercial property and casualty insurance policies, coverage for insured losses that does not differ materially from the terms, amounts, and other coverage limitations applicable to losses arising from events other than acts of terrorism by complying with the mandatory availability requirements of 31 CFR 50.20 through 50.23.

2. Disbursements of the Federal share of compensation to affiliated insurers, if applicable, will be accomplished in accordance with 31 CFR Part 50 Subpart H.

Any false or fraudulent statements or claims may subject the insurer and 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 15 minutes 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 2 OMB No. 1505-0200 (Exp.: X/X/2020)

TRIP 02B Schedule B