OMB No. 1505-0257

Expiration: March 31, 2025

TERRORISM RISK INSURANCE PROGRAM 2023 DATA CALL: SMALL INSURERS

INSURER GROUP AFFILIATIONS

C H

3 NAIC Group Code Insurer Group Name 3 Total 2021 Policyholder Surplus

4 4 Total 2021 TRIP-Eligible DEP (all lines)

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

B

B

G

Affiliations

Page 1 of 9
OMB No. 1505-0257

Expiration: March 31, 2025

TERRORISM RISK INSURANCE PROGRAM 2023 DATA CALL: SMALL INSURERS

DIRECT EARNED PREMIUM (DEP) (JURISDICTION)

2

C D E F G H

5 TRIP-Eligible Line of Coverage

NAIC Line 

(Commercial Only)

Total 2022 TRIPEligible DEP (all 

policies)

Total 2022 TRIPEligible DEP 

(Terrorism Risk 

Coverage Declined)

Total 2022 TRIP-Eligible 

DEP (Terrorism Risk 

Coverage Provided for 

Disclosed $0 Charge)

Total 2022 TRIP-Eligible 

DEP (Terrorism Risk 

Coverage Provided with a 

Premium Charged)

Total 2022 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 $ - $ - $ - $ - $ -

 Jurisdiction:

B

Premium (Juris.)

Page 2 of 9
OMB No. 1505-0257

Expiration: March 31, 2025

TERRORISM RISK INSURANCE PROGRAM 2023 DATA CALL: SMALL INSURERS

STANDALONE TERRORISM (NATIONWIDE)

C

2 Element Amount

3 2022 DEP for Standalone Terrorism Policies

4 Portion of 2022 DEP Providing Coverage for Losses for Certified Acts of Terrorism under TRIP

5 Portion of 2022 DEP Providing Coverage for Losses Arising from Other (Non-Certified) Acts of 

Terrorism

6 2022 Number of Standalone Terrorism Policies Issued

7 2022 Number of Standalone Terrorism Policies Issued Providing Coverage for Losses for 

Certified Acts of Terrorism Under TRIP

8 2022 Property Insurance Exposure for Standalone Terrorism Policies Providing Coverage for 

Losses for Certified Acts of Terrorism Under TRIP

9 Total 2022 Limits of Liability for Standalone Terrorism Policies Providing Coverage for Losses 

for Certified Acts of Terrorism Under TRIP

B
OMB No. 1505-0257

Expiration: March 31, 2025 

TERRORISM RISK INSURANCE PROGRAM 2023 DATA CALL: SMALL INSURERS

CYBER (NATIONWIDE)

C D E

2 Element Standalone Cyber

Cyber Coverage 

provided as part of a 

Package Policy Totals

3 Total 2022 TRIP-Eligible DEP (All Cyber Policies) $ -

4 Total 2022 Cyber DEP in TRIP-Eligible Lines of Insurance (Terrorism Risk Coverage Declined) $ -

5 Total 2022 Cyber DEP in TRIP-Eligible Lines of Insurance (Terrorism Risk Coverage Provided) $ -

6 Total 2022 TRIP-Eligible DEP Charged for Terrorism Risk Coverage Under Cyber Policies $ -

7 Total 2022 Non-TRIP-Eligible DEP (All Cyber Policies) $ -

8 Total 2022 Number of Cyber Policies Issued in TRIP-Eligible Lines of Insurance 0

9 Total 2022 Number of Cyber Policies Issued (Terrorism Risk Coverage Provided) 0

10 Total 2022 Number of Cyber Policies Issued in Non-TRIP-Eligible Lines of Insurance 0

11 Total 2022 Number of all Cyber Policies Issued 0

12 Total 2022 Number of all Cyber Policies Issued to Small Policyholders (100 or fewer employees or less than 

$10 million in revenue) 0

13 Total 2022 Number of all Cyber Policies Issued to Medium Policyholders (101-500 employees or $10-$100 

million in revenue) 0

14 Total 2022 Number of all Cyber Policies Issued to Large Policyholders (501 or more employees or moer than 

$100 million in revenue) 0

15 Total 2022 DEP of all Cyber Policies Issued to Small Policyholders (100 or fewer employees or less than $10 

million in revenue) $ -

16 Total 2022 DEP of all Cyber Policies Issued to Medium Policyholders (101-500 employees or $10-$100 

million in revenue) $ -

17 Total 2022 DEP of all Cyber Policies Issued to Large Policyholders (501 or more employees or more than 

$100 million in revenue) $ -

18 Total 2022 Policy Limits for Cyber Policies Issued in TRIP-Eligible Lines of Insurance $ -

19

Total 2022 Policy Limits for Cyber Policies Issued in TRIP-Eligible Lines of Insurance Providing Coverage for 

Losses for Certified Acts of Terrorism Under TRIP $ -

20 Total 2022 Policy Limits for Cyber Policies Issued in Non-TRIP-Eligible Lines of Insurance $ -

21 Total 2022 Policy Limits for Cyber Extortion under Cyber Policies Issued in TRIP-Eligible Lines of Insurance $ -

B

Cyber (US)

Page 4 of 9
OMB No. 1505-0257

Expiration: March 31, 2025 

TERRORISM RISK INSURANCE PROGRAM 2023 DATA CALL: SMALL INSURERS

CYBER (NATIONWIDE)

22

Total 2022 Policy Limits for Ransom Payments for Cyber Extortion under Cyber Policies Issued in TRIPEligible Lines of Insurance $ -

23

Total 2022 Policy Limits for Cyber Extortion under Cyber Policies Issued in Non-TRIP-Eligible Lines of 

Insurance $ -

24

Total 2022 Policy Limits for Ransom Payments for Cyber Extortion under Cyber Policies Issued in Non-TRIPEligible Lines of Insurance $ -

25 Total 2022 Direct Losses Paid for Cyber Extortion under all Cyber Policies Issued $ -

26 Total 2022 Direct Losses Incurred for Cyber Extortion under all Cyber Policies Issued $ -

27

Total 2022 Direct Losses Paid for Cyber Extortion (Ransom Payment or Reimbursement Only) under all Cyber 

Policies Issued $ -

28 Total 2022 Number of Claims Associated with Payments reported in Line 27 $ -

29

Total 2022 Direct Defense and Loss Containment Amounts Paid for Cyber Extortion under all Cyber Policies 

Issued $ -

30

Total 2022 Direct Defense and Loss Containment Amounts Incurred for Cyber Extortion under all Cyber 

Policies Issued $ -

Cyber (US)

Page 5 of 9
OMB No. 1505-0257

Expiration: March 31, 2025

TERRORISM RISK INSURANCE PROGRAM 2023 DATA CALL: SMALL INSURERS

EXPOSURE BASES BY JURISDICTION

2

C D E F G H I J K L M N

5 TRIP-Eligible Line of Coverage

NAIC Line 

(Commercial 

Only)

Total 2022 TRIPEligible Property 

Exposure (Terrorism 

Risk Coverage 

Provided)

Total 2022 TRIPEligible Property 

Exposure (Terrorism 

Risk Coverage 

Provided and NBCR 

Risks Not Excluded)

Total 2022 

Policyholder 

Deductibles for TRIPEligible Property 

Policies (Terrorism Risk 

Coverage Provided)

Total 2022 TRIPEligible Property 

Exposure (Terrorism 

Risk Coverage 

Declined)

Total 2022 

Policyholder 

Deductibles for TRIPEligible Property 

Policies (Terrorism Risk 

Coverage Declined)

Total 2022 Limits of 

Liability for TRIPEligible Policies 

(Terrorism Risk 

Coverage Provided)

Total 2022 TRIPEligible Limits of 

Liability (Terrorism 

Risk Coverage 

Provided and NBCR 

Risks Not Excluded)

Total 2022 

Policyholder 

Deductibles for TRIPEligible Liability 

Policies (Terrorism Risk 

Coverage Provided)

Total 2022 Liability for 

TRIP-Eligible Policies 

(Terrorism Risk 

Coverage Declined)

Total 2022 

Policyholder 

Deductibles for TRIPEligible Liability 

Policies (Terrorism Risk 

Coverage Declined)

Total 2022 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 $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -

B

 Jurisdiction:

Exposure Bases (Juris.)

Page 6 of 9
OMB No. 1505-0257

Expiration: March 31, 2025

TERRORISM RISK INSURANCE PROGRAM 2023 DATA CALL: SMALL INSURERS

PLACES OF WORSHIP (NATIONWIDE)

(NAICS, SIC, ISO, or OTHER)

D E F G H I J K L M N O

All Categories

3 Description

Total 2022 DEP 

Charged for 

Terrorism Risk 

Coverage

Total 2022 TRIPEligible DEP 

(Terrorism Risk 

Coverage 

Declined)

Total 2022 TRIPEligible DEP 

(Terrorism Risk 

Coverage 

Provided)

Total 2022 TRIPEligible DEP

Total 2022 DEP 

Charged for 

Terrorism Risk 

Coverage

Total 2022 TRIPEligible DEP 

(Terrorism Risk 

Coverage Declined)

Total 2022 TRIPEligible DEP 

(Terrorism Risk 

Coverage 

Provided)

Total 2022 TRIPEligible DEP

Total 2022 DEP 

Charged for 

Terrorism Risk 

Coverage

Total 2022 TRIPEligible DEPTotal 2022 TRIPEligible DEP

4 NAICS 813110 Religious Organizations $ - $ - $ -

5 SIC 8661 Religious Organizations $ - $ - $ -

6 ISO 0900 (Property)

41650 (Liablity) Religious Organizations $ - $ - $ -

7 Other Places of Worship $ - $ - $ -

8 TOTALS: $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -

Workers' Compensation

Code

C

Property Liability

Places of Worship (US)

Page 7 of 9
OMB No. 1505-0257

Expiration: March 31, 2025

TERRORISM RISK INSURANCE PROGRAM 2023 DATA CALL: SMALL INSURERS

REINSURANCE (NATIONWIDE)

C D

2 Element Response Description or Explanation (if any)

3 Size of TRIP 2022 Deductible (Cell H4 of Insurer Group Affiliations Chart x 20%)

4 Total 2022 Limits Any One Loss of Purchased Treaty Reinsurance Covering TRIP Loss

5 Total 2022 Aggregate Limits of Purchased Treaty Reinsurance Covering TRIP Loss

6 2022 Attachment Point Any One Loss of Purchased Treaty Reinsurance Covering TRIP Loss

7 2022 Co-Participation Share of Purchased Treaty Reinsurance Covering TRIP Loss

8 Total 2022 Limits Any One Loss of Purchased Treaty Reinsurance Covering Natural Catastrophe Loss

9 Total 2022 Aggregate Limits of Purchased Treaty Reinsurance Covering Natural Catastrophe Loss

10 2022 Attachment Point Any One Loss of Purchased Treaty Reinsurance Covering Natural Catastrophe Loss

11 2022 Co-Participation Share Any One Loss 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, 2022 Limits Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving WC Loss

16 If Yes, 2022 Attachment Point Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving WC Loss

17 If Yes, 2022 Co-Participation Share (if any) Any One Loss 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, 2022 Limits Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving Property Loss

20 If Yes, 2022 Attachment Point Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving Property 

Loss

21 If Yes, 2022 Co-Participation Share (if any) Any One Loss 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, 2022 Limits Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving Liability Loss

24 If Yes, 2022 Attachment Point Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving Liability 

Loss

25 If Yes, 2022 Co-Participation Share (if any) Any One Loss of NBCR Reinsurance for Certified Acts of Terrorism involving 

Liability Loss

26 Any Other Reinsurance Exclusions Specifically Applicable to Certified Acts of Terrorism Under TRIP?

27 ZIP Code Associated with Largest Probable Maximum Loss (PML)

28 Largest PML at a Single Location (Amount)

B

Reinsurance (US)

Page 8 of 9
Notice under the Paperwork Reduction Act

We estimate it will take you about 32 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.