D Insurance of an export buyer credit against the risk of non payment Notification of a threat of an insurance loss

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NOTIFICATION OF A THREAT OF AN INSURANCE LOSS
GIC type D
  Insurance Contract number:
  Insurance Decision number (for framework contracts):
  Cause of an insurance loss according to GIC D Art. VIII.:
  Supplementary insurance of exchange rate risk (for contracts before December 31, 2006):
 
I. Insured
  Commercial name:
  Company Identification No.:
  Seat:
  Phone:
  Fax:
  E-mail:
  Contact Person:
  Bank Connection:
  Authorised Person 1):
1) Person for whom the right to indemnification comes into existence as a result of an insurance loss - to be filled in only if it is other person than the insured
II. Debtor
  Commercial name:
  Seat:
  State:
  Debtor:  
  Phone:
  Fax:
  E-mail:
  Contact Person:
  Bank Connection:
III. Data on a threat of an insurance loss:
Currency From To Principal Interest
rate
Number
of days
Interest Owed
principal
Total  
Owed principal + interest  
  Share of goods of Czech origin in the total export exceeds 50%:    
IV. Commentary:
  Description of business transaction:
  Reasons and circumstances leading to a threat of an insurance loss (must be filled-in):
  Following steps have been made for recovery/ensurance of the receivable (must be filled-in):
V. Instruction
  • the form has to be duly filled-in and signed by a person authorized to act outwardly on behalf of the company
  • the insured will continue in all necessary measures in cooperation with the insurer to prevent origination of an insurance loss or to lower its extent
  • the insurer has the right to take all necessary measures in cooperation with the insured or independently leading to prevention of an insurance loss or to lowering of its extent
VI. Attachments
  • Credit contract (buyer credit), documentation to individual drawings of the credit
  • Export Contract
  • Correspondence with the foreign debtor related to unpaid instalments
  • Documents ensuring recoverability of the extended credit (bank guarantees, state guarantees, Bills of Exchange, pledges and such)
  • Permits for transfer of goods or services and export licences (if required)
  • Documentation on extent of material damage and on circumstances causing it
  • Customs documents and export licence
  • Information whether the foreign debtor (foreign buyer) objected that the exporter or his sub-supplier did not comply with their contractual obligations and applied a counterclaim related to the insured contract or refused payment for other reasons
  • Other attachments:
  Number of attachments:  
  Date:
Signature of insured:   .......................................................................................
 
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