Terrorism Risk Insurance Program - Shedule C - U.s. Department Of Treasury printable pdf download

Terrorism Risk Insurance Program - Shedule C - U.s. Department Of Treasury

Control Number

(Treasury Use)

TERRORISM RISK INSURANCE PROGRAM

SCHEDULE C

BORDEREAU

Insurer or Insurer Group Name:

NAIC Insurer (or Group) Number:

TIN (if no NAIC #):

Calendar Year:

Data as of:

Field #:

CAT CODE

LOB CODE

LOC OF LOSS/

DOL - DATE OF LOSS

INSURER NUMBER INSURER NAME

CLAIM #

INSURED NAME INSURED TIN

EFF DT

EXP DT

NUMBER

PRIOR

STATE CD

(MM/DD/YYYY)

(MM/DD/YYYY) ( MM/DD/YYYY) INDICATOR

OF WC

CUMULATIVE

MO, MI or II CLAIMANTS LOSS PAYMENTS

Totals:

0.00

Instruction to add more lines

As this spreadsheet has been constructed with formulae for data fields that need to be totaled, please insert any additional data

records (rows) before (above) the “Totals” row.

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

Page 1

OMB No. 1505-0200 (Exp.: X/X/2020)

TRIP 02B Schedule C

Terrorism Risk Insurance Program - Shedule C - U.s. Department Of Treasury