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Insurance of a Medium and Long Term Export Supplier Credit Financed by a Bank »

Application for conclusion of an insurance contract

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APPLICATION

for insurance of a medium- and long-term supplier credit financed by a bank against the risk of non-payment

GIC type Cf

Applicant (bank, financial institution)

Export Contract

Subject:
to the country:
Purchase price:
Exporter:

Importer

Country:

I. Applicant

Commercial name of the applicant:
Company Identification No.:
Tax registration No.:
Address:
City:
Postcode:
Legal form:
Banking connection:
Account number:
Name and position of the statutory body:
Responsible person:
Phone:
Fax:
E-mail:

Applies for:	conclusion of the insurance promise
	conclusion of the insurance contract	insurance of refinancing expenses

II. Information on Exporter

Name of the Company:
Company Identification No.:
Tax registration No.:
Legal form:
Banking connection:
Account number:
Signing person (persons):
Number of employees:
Annual turnover for the last accounting period:
Balance sum for the last accounting period:

III. Contract on Cession of Receivable/s:

Subject of the Contract on Cession of Receivable/s:

Number and date of signing:

Document evidencing the origination of receivable/s:

Expected date of the cession of receivable/s:

IV. Export Contract:

Subject of the Export Contract (goods and services):

Expected:
Date of signing of the Export Contract:
Starting date of deliveries:
Finishing date of deliveries:
Number of partial deliveries:

Total amount of the Export Contract (in currency of the Export Contract):

Delivery clause

(according to INCOTERMS) from:

Advance Payment		%, i.e. in currency of the Export Contract:
Cash Payment		%, i.e. in currency of the Export Contract:
Credit (Payment Deferral)		%, i.e. in currency of the Export Contract:

Credit payment terms:
Payment deferral of credit until:		number of years:
number and periodicity of instalments:
interest rate:

Please attach the schedule of invoicing of deliveries and repayment of the supplier credit by the foreign importer (Attachment No. 1).

a) Obligations of the Exporter and penalties for their breach arising from the Export Contract

b) Obligations of the Importer and penalties for their breach

c) Collaterals for settlement of the purchase price
(state guarantee, bank guarantee, acceptance of a bill of exchange, and such)

Purchase price:	thous.	(in currency of the Export Contract)
Calculated profit:	thous.	(in currency of the Export Contract)
Credit amount:	thous.	(in currency of the Export Contract)
Interest amount:	thous.	(in currency of the Export Contract)

Share of foreign sub-deliveries in the Export Contract amount in %

1. Commercial name:
Delivery value:	thous.	(in currency of the Export Contract)
2. Commercial name:
Delivery value:	thous.	(in currency of the Export Contract)
Main domestic suppliers:
1. Commercial name:
Delivery value:	thous.	(in currency of the Export Contract)
2. Commercial name:
Delivery value:	thous.	(in currency of the Export Contract)

Sub-deliveries from companies in the country of importer

thous.

(in currency of the Export Contract)

V. Importer

Commercial name of the importer:
Address:
City:
Postcode:
Identification No.:
State:
Legal form of the importer:
Predominant ownership form (state, private):
Bank of Importer:
Address:
City:
Postcode:
State:
Relations of importer to other subject:
(capital group, parent company, subsidiary, other relation)

Names of other subjects which are in capital relations to the importer:

1.
2.
3.
4.
5.

Experience with the importer until now:

Total amount of receivables from the importer (in CZK thousand):

Of which overdue:

Mention all data known to you regarding the requested insurance which could be related with assessment of the risk of the business transaction and with the importer including your experience with fulfilment of contracts and compliance with payment terms.

Inseparable parts of this form are attachments:
No.1 - Schedule of invoicing of receivables and repayment of supplier credit by the foreign importer
No.2 - Declaration of the Exporter on the share in the value of export
No.3 - Questionnaire for assessment of environmental impact of the export including the declaration of the Exporter
No.4 - Declaration of the Exporter on compliance with legal provisions against bribery in international trade.

Please attach available commercial and other information (forms) related to the importer.

All information has confidential character and serves the Export Guarantee and Insurance Corporation for processing of the draft of the insurance contract (insurance promise contract).

Declaration of applicant for insurance

I declare herewith that I am acquainted with General Insurance Conditions "Cf" and confirm that data entered in this form are truthful, complete and no important data known as on day of submission of this application for insurance have been omitted or withheld.

I obligate myself to inform the insurer without delay on other circumstances and changes related to the requested insurance which could occur after the submission of this application.

I take notice of my duty to reimburse the insurer all expenses accrued in connection with verification of the insurance risk also in case the insurance contract (insurance promise contract) will be prepared on the basis of data entered in this form and the contract will not be signed.

Commercial name of the applicant:
Name and position of the statutory body:
Date:
Signature: .......................................................................................

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