C Insurance of a Medium and Long Term Export Supplier Credit against the Risk of Non Payment Application for Insurance of a Medium and Long Term Export Supplier Credit against the Risk of Non Payment (GIC type C)

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APPLICATION
for insurance of a Medium and Long Term Export Supplier Credit against the Risk of Non Payment
GIC type C
pursuant to Act No. 58/1995 Coll.1

1 Act No. 58/1995 Coll., on the Insurance and Financing of Exports with State Support and on the Supplement to Act No. 166/1993 Coll., on the Supreme Audit Office, as amended, as amended

  Applicant for insurance:
  Export Contract:
  Subject:
  To country:
  Manufacturer:
  Total export value2:
2 price agreed in the Export Contract
I. Applicant for insurance (exporter)
  Name:
  Company registration number:
  VAT ID No.:
  File number in Business Register:
  Registered office:
  Address for postal service:  
     Street
     City
     Post code
  Legal form:
  Applicant's bank:
  A/C No.:
  Persons authorized to sign for the
  company:
  Contact person:
  Telephone:
  Fax:
  E-mail:
  Tying the payment of benefit required:
  (If yes, identify the entity and bank details, including account number.)
  Applies for:
II. Information about the exporter
  Number of employees:
  Annual turnover for the last accounting
  period:
  Relation of the exporter to other entities3:
Names of other entities that are financially linked groups3 with the guarantor:
  1.
  2.
  3.
  4.
  5.

3 the parent company, a subsidiary and another financially linked group. Financially linked group means mainly the cases when:

  • one entity holds a property interest (direct or mediated) or interest in voting rights of more than 10% of another entity or other entities or the ability to appoint members of the statutory and supervisory body of the other entity or entities, or the entity in relation to the controlling and controlled entity;
  • legal entities have the same members of statutory and supervisory bodies or senior management, or relatives in these positions (especially family members);
  • entities are economically dependent on each other (for example, trade relations are higher than 40% of total supplies), or
  • entities are interconnected by guarantees, pledges, credits or loans.
III. Export contract
  Subject-matter of the Export Contract
  (goods and services):
  The Export Contract was concluded   on 
 - state the state of negotiations:
  Conditions of effect under the Export Contract:
  Expected date of commencement of
  deliveries:
  Expected date of termination of deliveries:
  Expected number of sub-deliveries:
  Total export value2
  (in the currency of the Export Contract):
Delivery parity  (under INCOTERMS) from year: 
Payment terms of the Export Contract:
  Down payment   %, i.e. in the currency
  of the Export Contract: 
  Payments on delivery   %, i.e. in the currency
  of the Export Contract: 
  Deferred maturity of export receivable 
  (export credit) 
 %, i.e. in the currency
  of the Export Contract: 
  Period of repayment of the export receivable 
  (export credit):
 years and   months
  Other conditions of the export credit (deferment of payments, number and frequency of repayments):
  Form of recouping the export receivable (export credit):
  Calculated profit   %, i.e. in the currency
  of the Export Contract: 
  Moment of rise of receivable under the
  Export Contract:
  In the Annex No. 2 attach billing schedule of deliveries and repayment of supplier credit by the importer.
  a) Obligations of the exporter and sanctions for their non-fulfilment under the Export Contract
  b) Obligations of the importer and sanctions for their non-fulfilment under the Export Contract
  c) Form of recouping the purchase price (guarantees, bills of exchange, letters of credit, etc.)
  d) Other proposed conditions to the export contracts, namely the importer's liability to submit documents necessary
for its financial evaluation and the financial evaluation of the guarantors, i.e. mainly financial statements of the debtor
and guarantor
  Number of jobs created in the CR by the export:
  Number of jobs maintained in the CR by the export:
National percentage values:
 Main subcontractors (manufacturers):
  1. Sub-deliveries from contractors based in the Czech Republic4
    1. Name:
        Delivery value:  thousand   (in the currency of the Export Contract)
 % of the total export value
    2. Name:
        Delivery value:  thousand   (in the currency of the Export Contract)
 % of the total export value
   In case of need add other important subcontractors
    Percentage value of Czech deliveries on the total export value: 
  2. Percentage value of local deliveries in the importer's country5 in the total export value
      thousand   (in the currency of the Export Contract)
      % of the total export value
  3. Sub-deliveries from third countries outside the country of import5
    1. Country:
        Name:
        Delivery value:  thousand   (in the currency of the Export Contract)
 % of the total export value
    2. Country:
        Name:
        Delivery value:  thousand   (in the currency of the Export Contract)
 % of the total export value
  In case of need add other important subcontractors
    Percentage value of sub-deliveries from third countries on the total export value: 

2 price agreed in the Export Contract

4 Exceeding 5% of the total export value

5 costs of goods and services in the importer's country under the OECD Consensus

IV. Importer/debtor (foreign buyer)
  Name:
  Company registration number:
  VAT ID No.:
  Registered office:
  Address for postal service:  
     Street
     City
     Country
  Legal form:
  Predominant form of ownership
  (state, private):
  Main field of activities:


  Importer's bank:
  Registered office:
  Address for postal service:  
     Street
     City
     Country
  Relation of the importer to other entities3:
Names of entities that are part of a group financially linked with the importer3:
  1.
  2.
  3.
  4.
  5.
  Your experience with the debtor or importer so far:
  The amount of your receivables from the debtor/importer (in thousands CZK):
  Of which overdue:
Guarantor:
  Name:
  Company registration number:
  VAT ID No.:
  Registered office:
  Address for postal service:  
     Street
     City
     Post code
     Country
  Legal form:
  Predominant form of ownership
  (state, private):
  Relation of the guarantor to other entities3:
Names of other entities that are financially linked groups3 with the guarantor3:
  1.
  2.
  3.
  4.
  5.

3 the parent company, a subsidiary and another financially linked group. Financially linked group means mainly the cases when:

  • one entity holds a property interest (direct or mediated) or interest in voting rights of more than 10% of another entity or other entities or the ability to appoint members of the statutory and supervisory body of the other entity or entities, or the entity in relation to the controlling and controlled entity;
  • legal entities have the same members of statutory and supervisory bodies or senior management, or relatives in these positions (especially family members);
  • entities are economically dependent on each other (for example, trade relations are higher than 40% of total supplies), or
  • entities are interconnected by guarantees, pledges, credits or loans.
V. Description of the business case
  Include a description of the business case here, i.e. a detailed description of the subject of export, references to similar transactions of the exporters in terms of the territory of export; how the exporter or the funding bank was contacted with the business case, whether the parties to transactions are known to the exporter or the bank from previous business cases or completely new, what are the benefits of the transaction for the exporter (to strengthen its position in the market, to enter a new market, to maintain an existing business relationship, etc.), funding bank and for the Czech Republic, what are the main expectable risks and how such risks can be addressed in a practical manner.
 
Provide other products required with EGAP insurance for this business case (insurance Z, V, B, C, D, E etc.) and a current sate of insurance negotation.
Provide any other specific information known to you regarding the required insurance which could be related to the assessment of risk of the business case and to the debtor, investor and other entities involved in the investment, including your experience with the performance of contracts and compliance with payment conditions.
The following annexes are an integral part of this form:
Annex No. 1 -  Basic terms and conditions - insurance of middle-term and long-term export supplier's credit „C“
Annex No. 2 -  Schedule of supply invoicing and repayment of the supplier's credit by the importer
Annex No. 3 -  Exporter's statement on the export value percentage
Annex No. 4 -  Exporter's declaration on compliance with legal provisions against bribery in international trade and in prosecution of the exporter
Annex No. 5 -  Questionnaire to assess the environmental and social impact of the export including the exporter's statement
Annex No. 6 -  Overview of submitted documents for analysis
All information is confidential and is used by the insurer Exportní garanční a pojišťovací společnost, a.s. (Export Guarantee and Insurance Corporation) only for the preparation of insurance including a decision on the provision of insurance and the preparation of a draft insurance contract (contract on the promise of insurance). Exportní garanční a pojišťovací společnost, a.s. (Export Guarantee and Insurance Corporation) reserves the right to request submission of other information and documents necessary for the assessment of the application for insurance and for taking out the insurance.
Statement of the applicant for insurance
of a a Medium and Long Term Export Supplier Credit
against the Risk of Non Payment– „C“
I declare that:
  1. have acquainted myself with the General Insurance Terms and Conditions of type "C" and basic terms and conditions of insurance of a medium and long term export supplier credit against the risk of non payment listed in Annex 1, and I confirm that the information stated in this application and its annexes is correct and complete and no important facts known as of the date of filing this application for insurance have been omitted or withheld and are not in conflict with the basic terms and conditions of insurance and the General Terms and Conditions of type "C",
  2. a the above business case for the insurance of which I am applying is, based on preliminary assessment, feasible in terms of its structure and financial health of all the stakeholders, and that I have a serious intent to further negotiate the provision of insurance of this business case, and
  3. I have the consent of all the stakeholders to provide information and documents listed in the submitted application, its annexes and where other material is necessary to assess the application for insurance and to take out insurance, I will request such consent.
I agree to immediately inform the insurer of any additional facts and changes applicable to or related to the requested insurance which occur after submitting this application.
I agree with the provision of data, information and documents provided by me and handed over to the insurer in connection with and regarding insurance to persons providing the insurer with information and assessment and bodies of the company of the insurer including shareholder representatives, and I agree with the provision of such data, information or documents to the respective bodies and persons if provided so by applicable legislation, and with their provision to a reinsurance company and third parties to the extent necessary for negotiations on the conclusion of an insurance contract and for its conclusion.
  Name of the applicant:
  Person(s) authorized to act for the applicant:
  In   dated
[Signature of person(s) authorized to act for the applicant]
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