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Insurance TRIA & Fee Form

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INSURANCE TRIA & FEE FORM

Insured / Applicant Information

Insured Name:

Phone:

Email:

Policy Information

Policy Number:

Policy Type:

Limit of Insurance:

Deductible:

Annual Premium:

Policy Period From:  To:

TRIA Coverage Election and Acknowledgment

The Terrorism Risk Insurance Act (TRIA) provides a federal backstop for certain certified acts of terrorism. By completing this form the insured elects coverage status for certified acts of terrorism and acknowledges that an assessment or fee may be charged in accordance with applicable law and policy provisions.

TRIA Assessment and Fee Calculation

The insured acknowledges and agrees that the insurer will calculate any TRIA-related assessment or fee in accordance with applicable statutory and regulatory rules. The insurer may collect such fee directly or by endorsement to the policy. Complete the fields below to document the premium and fee basis.

TRIA Assessment Rate (percent):

Calculated TRIA Fee Amount:

Coverage Selections and Limits

Indicate the scope of terrorism coverage applicable under this policy and any sublimits or endorsements. If an endorsement is attached, reference endorsement number.

Exclusions, Limitations and Notices

Unless otherwise provided by endorsement, certified acts of terrorism are subject to policy terms, conditions, and applicable TRIA limitations. The following matters apply and are acknowledged by the insured:

  • TRIA coverage applies only to certified acts of terrorism as defined by federal law; certain exclusions including war, nuclear, and intentional acts may remain excluded by policy or statute.
  • The federal government may allocate payments under TRIA subject to appropriation; the insurer's obligation is limited by law and by the policy.
  • The insured must promptly notify the insurer of any material change in risk, ownership, or exposure that would affect premium or TRIA applicability.
  • Insurer reserves the right to audit premium and records to determine final assessment amounts; insured agrees to cooperate with audits and to remit additional assessments if determined.

Documentation Checklist

Attach or indicate all applicable documents submitted with this form.

Certification and Authorization

By signing below, the undersigned certifies that the information provided on this form and any attachments is true, complete and correct to the best of the undersigned's knowledge. The undersigned authorizes the insurer to assess and collect any TRIA-related fee or assessment permitted under law and to adjust premium as necessary. The undersigned acknowledges that willful misrepresentation of material facts may result in denial of coverage, rescission, or other remedies permitted by law.

The undersigned agrees to cooperate with any insurer or government audit or inquiry relating to TRIA assessments and to provide records reasonably required to verify premium and covered exposures. This certification is given under penalty of perjury to the extent permitted by law.

Signature

Applicant Name:

Title/Capacity:

Signature:

Date:

Phone:

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What the Insurance TRIA & Fee Form Is and When It Applies

The Insurance TRIA & Fee Form documents insurer reporting and fee remittance obligations under the Terrorism Risk Insurance Act (TRIA) framework and applicable state regulations. Insurers use the form to report aggregate insured losses, calculate program-triggering thresholds, and remit the federal share or assessment-related fees. The form typically collects policy counts, covered loss amounts, deductible calculations, and payer identification. It supports regulatory oversight and ensures consistent application of TRIA benefits and assessments between insurers, reinsurers, and the U.S. Department of the Treasury or designated state authorities.

Why the Insurance TRIA & Fee Form Matters to Carriers and Risk Managers

Completing the Insurance TRIA & Fee Form correctly protects an issuer’s access to federal compensation after certified terrorism losses and ensures accurate fee allocation. The form aligns insurer reporting with statutory thresholds, enables timely federal reimbursement where available, and documents fee obligations that fund the terrorism insurance backstop. Accurate submissions minimize audit exposure, reduce assessment disputes, and preserve eligibility for program benefits.

Why the Insurance TRIA & Fee Form Matters to Carriers and Risk Managers

Who Typically Completes the Insurance TRIA & Fee Form

Insurers, reinsurers, regulatory compliance teams, and third-party administrators commonly prepare and file this form on behalf of covered entities.

  • Regulatory Compliance Teams: Prepare aggregated loss data, reconcile internal ledgers, and certify statutory calculations prior to filing.
  • Claims and Finance Departments: Supply claim-level totals, deductible computations, and loss allocations needed for fee calculations.
  • Third-Party Administrators: Collect data from insured portfolios and submit filings when acting under contractual authority.

Final review should confirm signer authority, numeric reconciliation to financial statements, and inclusion of any required supporting schedules.

Core Elements Found on a Professional Insurance TRIA & Fee Form

A complete form groups identification, loss detail, fee calculation, certification, and remittance instructions into clear sections so reviewers can verify eligibility and compute assessments efficiently.

Insurer ID

Legal entity name, NAIC number, FEIN, and primary mailing address used to match regulatory records and tax identifiers.

Policy Counts

Counts by line of business and policy type so regulators can verify market exposure and scope of covered risks.

Loss Totals

Aggregate insured loss amounts attributable to certified terrorism events, broken down by jurisdiction and policy coverage.

Deductible Calculation

Methodology and numeric deduction to determine the insurer’s retention before federal or pooled reimbursement applies.

Fee Computation

Line-by-line fee schedule showing assessment rates, taxable base, and final remittance amount required under TRIA rules.

Certification

Authorized signer block attesting to accuracy, with signature, title, date, and contact information for follow-up.

Step-by-Step: Completing and Submitting the Insurance TRIA & Fee Form

Follow these sequential steps to collect data, verify calculations, obtain approvals, and submit the form to the correct authority.

  • 01
    Gather Data: Compile policy counts, claim totals, and accounting reconciliations for the reporting period.
  • 02
    Calculate Fees: Apply the statutory assessment rate and record rounding conventions used on the form.
  • 03
    Internal Approval: Obtain sign-off from compliance, finance, and legal before finalizing the submission.
  • 04
    Submit Filing: Send the completed form and supporting schedules to the designated federal or state recipient.

Configuring an Online Submission Workflow for the Form

Set up a repeatable digital workflow that enforces field validation, collects signatures, and archives completed filings for audit.

Field Validation Rules Require numeric format for loss and fee fields
Signer Sequence Compliance officer → CFO → Authorized officer
Authentication Method Use email + SMS code for signer verification
Document Retention Store signed PDF with audit trail and exportable CSV
Notification Settings Auto-notify reviewers when action is required

Typical Processing Flow: From Data Collection to Remittance

This flow describes who does what and the handoffs required to produce an auditable filing and payment.

  • Data Capture: Claims and finance export loss totals to a reconciliation worksheet
  • Review & Certify: Compliance reviews figures and certifies accuracy
  • Sign & Approve: Authorized officer signs the completed form
  • File & Pay: Submit form and remit assessed fee to the appropriate authority

Digital Submission and Signing Requirements

Confirm the e-submission platform supports required authentication, audit logging, and secure storage before use.

  • Authentication: Multi-factor recommended
  • Audit Trail: Timestamped action logs required
  • File Formats: PDF/A or PDF preferred

Ensure the chosen platform can produce a tamper-evident signed PDF, export the audit trail, and preserve records for the required retention period under federal and state law.

Key Deadlines and Timeframes to Watch

Timelines vary by reporting period, statutory triggers, and payer instructions; confirm filing windows with the receiving agency or treasury office.

W-9 / Payer Requests:

No fixed filing deadline; provide upon payer request

1099-NEC Reporting:

Producer/agent compensation deadlines typically align with Jan 31 reporting windows

Form 1040 Cycle:

Tax year deadlines (e.g., April 15) affect related reconciliations

TRIA Remittance:

Submit fee payments per Treasury or state schedule

RON/Notary Timing:

If notarized, allow scheduling time for remote or in-person notary sessions

Common Preparation Errors to Avoid

  • Mismatched entity name or FEIN between the form and tax records creates validation holds and can delay remittance processing.
  • Omitting jurisdiction subtotals makes it difficult for regulators to reconcile state-level exposures and may trigger follow-up audits.
  • Using inconsistent rounding methods across worksheets can change the fee total and provoke disputes with regulatory reviewers.
  • Failing to attach required supporting schedules or claim detail often results in rejected filings or requests for supplemental documentation.

Penalties and Compliance Risks from Incorrect Filings

Tax Penalties: Per-Form fines possible
I-9 Exposure: Related employment documentation fines
Assessment Disputes: Late or incorrect fees may accrue interest
Audit Risk: Incomplete filings increase audit probability
Notary Invalidity: Missing journal or improper RON may void authentication
HIPAA Breach: Unauthorized PHI disclosure can trigger 45 CFR penalties

Required Information and Data Elements at a Glance

Entity Identifier: FEIN
Regulatory Code: NAIC number
Period Covered: Reporting period
Loss Totals: Aggregate USD
Fee Total: Remittance USD
Signer Details: Name, title, date

eSignature Provider Comparison for Filing and Signing the Form

Common provider options for e-signature and workflow automation are shown with base pricing and key capabilities relevant to secure filing and compliance.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently Asked Questions and Practical Answers

Answers address common legal, procedural, and technical questions about signing, filing, and correcting the Insurance TRIA & Fee Form.


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