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TERRORISM RISK INSURANCE PROGRAM

NOTICE OF PROPOSED SETTLEMENT OF THIRD-PARTY CLAIM

REQUEST FOR APPROVAL

Pursuant to 31 CFR Part 50, Subpart K (Sections 50.102 and 50.103), settlements of certain causes of 

action for property damage, personal injury, or death arising out of – or related to – certified acts of 

terrorism require Treasury's advance approval as a condition precedent for inclusion in an insurer's 

aggregate insured losses in its request for Federal share of compensation under the Terrorism Risk 

Insurance Program (Program). You should refer to the Program Rules for the advance approval 

requirements, which are available online at https://home.treasury.gov/system/files/311/Regulations.pdf. 

Use this form to submit a proposed settlement for review and processing. Please attach continuation 

sheets, as needed. After it has been determined that all required information is present, this form will be 

forwarded to Treasury for consideration. A separate completed form is required for each proposed 

settlement. If a field does not apply to the settlement, enter zero (0) in fields requesting financial figures, 

or N/A for other fields, to signify that the entry is not applicable.

A. Insurer or Insurer Group Name: 

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

C. Calendar Year of Event: 

D. Authorized Contact for the claim (if other than point of contact for Certifications): 

Contact’s Name: 

Contact’s Title: 

Organization/Company: 

Mailing Address: 

Telephone Number(s): 

E-mail Address: 
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E. Third Party Claim Information: 

Claim Number: 

ISO/PCS Cat Code: 

Insured Name: 

Policyholder Name: 

Line of Business: 

Date of Loss:

Third Party:

Are there any other Property and Casualty insurers involved with this loss? Yes No

If Yes, please identify:

F. Supporting Details

Please provide a brief description of the facts and circumstances, the types and layers of coverage, 

and include any appropriate amounts for the following.

Underlying Claim Against the Insured:

Insured’s Liability for the Loss:

Amounts Claimed Against the Insurer:

Operative Policy Terms:

Defenses to Coverages:

Insurer’s Estimate of All Damages Sustained:
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G. Itemized Statement of Damages

Please provide an itemization of all damages claimed by the third party, by category:

Category

Amount Claimed

(of the proposed settlement)

Actual: $

Economic Loss: $

Non-Economic Loss: $

Punitive Damages: $

Other: $

(Describe Other)

Total: $

H. Proposed Settlement Details

Proposed Settlement Amount: $

Net Amount to be received by the Third Party (if known) net of

fees and expenses of attorneys, experts and other professionals: $

If the settlement is approved, enter the claim amount that would 

be submitted on any Certifications of Loss: $

Related Questions Answer

If Yes, Please 

Specify Amount

1. Is any portion of the proposed settlement amount 

that is attributable to an insured loss or losses 

involving personal injury or death in the aggregate 

$2 million or more per third-party claimant, 

regardless of the number of causes of action or 

insured losses being settled?

Yes

No

Uncertain 

$

2. Is any portion of the proposed settlement amount 

that is attributable to an insured loss or losses 

involving property damage (including loss of use) in

the aggregate $10 million or more per third-party 

claimant, regardless of the number of causes of 

action or insured losses being settled?

Yes

No

Uncertain 

$

3a. Is any amount of the proposed settlement 

attributable to punitive or exemplary damages 

(whether or not specifically so described as such 

damage)?

Yes

No

Uncertain 

$
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3b. Did the third party assert a claim for punitive or 

exemplary damages in any filed or threatened legal 

action against the insurer?

Yes

No

Uncertain 

3c. If Yes to 3a or 3b, describe the nature of the claim or 

conduct the third party alleged entitled it to punitive 

or exemplary damages.

4a. Was any amount received by the third party from the 

United States pursuant to any other Federal 

program for compensation of insured losses related 

to an act of terrorism? (see 31 CFR 50.71(b)(2)) 

Yes

No

Uncertain 

$ 

4b. If Yes to 4a, which Federal agency?

4c. If Yes to 4a, does the proposed settlement already 

factor or offset amounts received from the United 

States pursuant to any other Federal program?

Yes

No

Uncertain 

$ 

5. Will any part of the proposed settlement amount

compensate for any items such as fees and 

expenses of attorneys, experts, or other 

professionals for their services and expenses 

related to the insured loss and/or settlement?

 Yes

No

Uncertain 

$ 

6. Was the proposed settlement negotiated by 

counsel?

Yes

No

Uncertain 

7a. Has the proposed settlement amount been 

approved by a Federal court?

Yes

No

Uncertain 

7b. Is the proposed settlement amount subject to 

approval by a Federal court?

Yes

No

Uncertain 

7c. If Yes to 7b, is such approval likely? Yes

No

Uncertain 

8a. Is this proposed settlement part of a class action? Yes

No

Uncertain 

8b. If Yes to 8a, please specify the class action case 

number.
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I. Supporting Materials

A statement from the insurer or its attorney in support of the proposed settlement has been attached. 

Yes No

The proposed terms of the written settlement agreement, including release language and subrogation 

terms, has been attached. 

Yes No

You have attached other information related to the insured loss that you would like Treasury to 

consider in evaluating the proposed settlement amount. 

Yes No

J. Executive Officer Certification

I hereby certify that the statements, data, calculations, and supporting documentation submitted with 

this request for approval of the proposed claim settlement are accurate and complete to the best of 

my information, knowledge and belief. Any false or fraudulent statements or claims may subject the 

insurer and signatory to criminal, civil, and/or administrative penalties.

1. The proposed settlement compensates for a bona fide loss that is an insured loss under the 

terms and conditions of the underlying commercial property and casualty insurance policy.

2. Attorneys' fees and expenses in connection with the settlement are reasonable and appropriate, 

in whole or in part, and have not caused the insured losses under the underlying commercial 

property and casualty insurance policy to be overstated.

3. All necessary steps consistent with appropriate business practices have been taken to 

reasonably, properly, and carefully investigate and ascertain the amount of the loss.

4. The settlement is for a third party's loss, the liability for which is an insured loss under the terms 

and conditions of the underlying commercial property and casualty insurance policy.

 

Name Officer Title Date

 

Signature

Notice under the Paperwork Reduction Act

We estimate it will take you about 4 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://trip.treasury.gov/TRIP/welcome.