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Page 1 OMB No. 1505-200 (Exp.: 1/31/2027) 

TRIP 04B

TERRORISM RISK INSURANCE PROGRAM

DIRECT WRITTEN PREMIUM AND END OF YEAR CALCULATION

A. Insurer Name: 

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

C. Calendar Year of Direct Written Premium (see instructions for guidance): 

D. Submitted for Period Ending: E. Type of submission: Original Correction

F. Step One A: 

Enter the insurer’s Direct Written Premium for commercial lines of business (listed below) 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. 

Columns 1B and 1C must sum to equal Column 1A. All entries should be provided in whole dollars.

Annual Statement Line of Business

- Column 1A -

Premium Reported 

on Statutory Page 

14 or Equivalent

Calendar Year 20xx

- Column 1B -

Premium Prior to 

Assessment Period

Calendar Year 20xx

(if applicable)

- Column 1C -

Premium During 

Assessment Period

Calendar Year 20xx

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) $ $ $
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TRIP 04B

Annual Statement Line of Business

- Column 1A -

Premium Reported 

on Statutory Page 

14 or Equivalent

Calendar Year 20xx

- Column 1B -

Premium Prior to 

Assessment Period

Calendar Year 20xx

(if applicable)

- Column 1C -

Premium During 

Assessment Period

Calendar Year 20xx

Line 27 – Boiler and Machinery $ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

(add more rows as needed)

G. Step One B:

Enter the insurer’s Direct Written Premium for commercial lines of business (listed below) as would typically be reported in Column 1C in Step 

One A. Columns 2 through 5 should sum to equal Column 1C. However, if necessary, additional columns (and sheets) may be added to 

complete the breakout of premium by policy year and to fully account for the entry in Column 1C. All entries should be provided in whole 

dollars.
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Page 3 OMB No. 1505-200 (Exp.: 1/31/2027)

TRIP 04B

Annual Statement Line of 

Business

- Column 1C -

Premium During 

Assessment 

Period

CY 20xx

- 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)

Line 1 – Fire $ $ $ $ $

Line 2.1 – Allied Lines $ $ $ $ $

Line 5.1 – Commercial 

Multiple Peril (non-liability 

portion) $ $ $ $ $
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TRIP 04B

Annual Statement Line of 

Business

- Column 1C -

Premium During 

Assessment 

Period

CY 20xx

- 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)

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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TRIP 04B

Annual Statement Line of 

Business

- Column 1C -

Premium During 

Assessment 

Period

CY 20xx

- 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)

$ $ $ $ $

(add more rows as needed)

STEP ONE TOTALS: $ $ $ $ $

H. Step Two:

Enter premium included in the Direct Written Premium numbers reported in Column 1C under Step One B that is for insurance coverage not 

subject to the Federal Terrorism Policy Surcharge. Columns 2 through 5 should sum to equal Column 1C. However, if necessary, additional 

columns (and sheets) may be added to complete the breakout of premium by policy year and to fully account for the entry in Column 1C. All 

entries should be provided in whole dollars.

Annual Statement Line of 

Business

- Column 1C -

Premium During 

Assessment 

Period

CY 20xx

- 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)

Line 1 – Fire $ $ $ $ $

Line 2.1 – Allied Lines $ $ $ $ $
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TRIP 04B

Annual Statement Line of 

Business

- Column 1C -

Premium During 

Assessment 

Period

CY 20xx

- 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)

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 $ $ $ $ $

$ $ $ $ $

$ $ $ $ $

$ $ $ $ $

$ $ $ $ $

$ $ $ $ $

$ $ $ $ $

$ $ $ $ $

(add more rows as needed)

STEP TWO TOTALS: $ $ $ $ $
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Page 7 OMB No. 1505-200 (Exp.: 1/31/2027)

TRIP 04B

I. 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.

- Column 1C -

Premium During 

Assessment 

Period

CY 20xx

- 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 One B Totals 

(as applicable) $ $ $ $ $

SUBTRACT

Step Two Totals 

(as applicable) $ $ $ $ $

EQUALS

Premium Subject 

to Surcharge $ $ $ $ $
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TRIP 04B

J. Step Four: 

Complete the following formulas to determine the insurer’s Federal Terrorism Policy Surcharge for the applicable year. 

- Column 1C -

Premium During 

Assessment 

Period

CY 20xx

- 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 Totals Not Applicable $ $ $ $

MULTIPLY BY 

Surcharge Percentage 

Established by Treasury 

for Individual Policy 

Years Not Applicable % % % %

EQUALS Surcharge by 

Policy Year Not Applicable $ $ $ $

Total Surcharge for Year

(add Columns 2 - 5): $

K. Step Five: 

Complete the following formula to determine the insurer’s Federal Terrorism Policy Surcharge due to Treasury for the applicable year. 

Step Four Total Surcharge for Year $

SUBTRACT Previously Reported and Remitted $

EQUALS Surcharge Still Due to Treasury for 

the Calendar Year $
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Page 9 OMB No. 1505-200 (Exp.: 1/31/2027) 

TRIP 04B

L. 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, and/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 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.