Control Number 

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Page 1 OMB No. 1505-0200 (Exp.: 1/31/2027) 

TRIP 02A Schedule A

TERRORISM RISK INSURANCE PROGRAM

SCHEDULE A 

DECLARATION OF DIRECT EARNED PREMIUM AND

CALCULATION OF INSURER DEDUCTIBLE

A. Insurer or Insurer Group Name: 

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

C. Calendar Year: 

D. Prior Calendar Year for Calculation of Direct Earned Premium (see instructions for guidance): 

E. List all affiliated insurers with premium subject to Terrorism Risk Insurance Act: 

Name NAIC # (or TIN if no NAIC #)

 (add more lines as needed)

F. Step One: Direct Earned Premium from the Annual Statement Exhibit of Premiums and Losses 

(NAIC Statutory Page 14), Column 2 for commercial lines of business, or from another appropriate 

reporting mechanism. See instructions for guidance.

Annual Statement Line of Business Direct Earned Premium

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 $

$

$

$

$

$

$

$

$
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Page 2 OMB No. 1505-0200 (Exp.: 1/31/2027) 

TRIP 02A Schedule A

Annual Statement Line of Business Direct Earned Premium

$

$

$

$

TOTAL: $

G. Step 2: Direct Earned Premium included in the numbers reported under Letter F that apply to

insurance coverage not to be included for purposes of TRIA. See instructions for guidance.

Annual Statement 

Line of Business

Direct Earned Premium Not 

to be Included per TRIA

Reason for Exclusion of 

Premium

$

$

$

$

$

(add more lines as needed)

TOTAL: $

H. Step 3: Direct Earned Premium, for lines of business included for purposes of TRIA, that were 

included in the numbers reported under Letter F and were ceded to a state residual market under a 

servicing carrier arrangement. See instructions for guidance.

Annual 

Statement Line 

of Business

Direct Earned 

Premium Ceded to 

Residual Market

Name of Residual Market 

for Which Insurer Serves as 

Servicing Carrier

State of 

Residual 

Market

$

$

$

$

$

$

(add more lines as needed)

TOTAL: $

I. Step 4: Direct Earned Premium for lines of business subject to TRIA that were not included in the 

numbers reported under Letter F and were distributed to the insurer by commercial lines state 

residual market entities. 

Annual 

Statement Line 

of Business

Earned Premium 

Received From

Residual Markets

Name of Residual Market 

Entity

State of 

Residual 

Market

$

$

$

$

$
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Page 3 OMB No. 1505-0200 (Exp.: 1/31/2027) 

TRIP 02A Schedule A

Annual 

Statement Line 

of Business

Earned Premium 

Received From

Residual Markets

Name of Residual Market 

Entity

State of 

Residual 

Market

$

(add more lines as needed)

TOTAL: $

J. Complete the following formula in order to determine the insurer’s Calendar Year deductible.

(F) Step 1 Total: $ + (I) Step 4

Total: $

–

(G) Step 2 Total: $ + (H) Step 3

Total: $

=

Direct Earned Premium: $

× 0.20 Deductible Factor

= Insurer Deductible 

under TRIA $

K. Certification

I hereby certify that the Direct Earned Premium data, calculations, and supporting documentation 

used to determine the insurer deductible are accurate and complete to the best of my information, 

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

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 6.5 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. .