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D

Application for conclusion of an insurance contract

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APPLICATION
for insurance of an export buyer credit against the risk of non-payment
GIC type D
Credit Contract
Applicant:
Debtor (usually a foreign bank):
Credit amount:
Length of repayment of the credit (in years):
Export Contract
Subject:
to the country:
Purchase price:
I. Applicant
Commercial name of the applicant:
Company Identification No.:
Tax registration No.:
Address:
City:
Postcode:
Legal form:
Banking connection:
Account number:
Statutory body:
Responsible person:
Phone:
Fax:
E-mail:
Applies for:     
    
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. Credit Contract
  /  credit contract No. from
conclude with the Debtor:
Commercial name:
Legal form:
Address:
City:
Postcode:
Identification No.:
State:
Predominant ownership form (state, private):
Credit amount in currency represents % of the purchase price
of the Export Contract.
Draw-down period of credit (in months):
Instalment deferral (in months.):
Number of credit instalment:
Principal: (in currency of the credit contract)
Interest: (in currency of the credit contract)
Fees (specification by type): (in currency of the credit contract)
Total insurance value (in currency of the Export Contract)
Please attach schedule of draw-down and repayment of the principal and interest requested for insurance. (Attachment No.1)
Conditions for draw-down of the credit (documents):
Form of securing the repayment of the credit (instalments, transfers):
IV. Export Contract:
Subject of the Export Contract (goods and services):
Concluded contract is valid as from      day
Conditions for the Export Contract becoming effective:
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:
Payment terms of the Export Contract:
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:
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
National contents:
Main suppliers (manufacturers):
1. Czech Republic, commercial name:
Delivery value: thous. (in currency of the Export Contract)
% from the total amount of the Export Contract
2. Sub-deliveries from companies in the country of importer
thous. (in currency of the Export Contract)
3. State: Commercial name:
Delivery value: thous. (in currency of the Export Contract)
% from the total amount of the Export Contract
4. State: Commercial name:
Delivery value: thous. (in currency of the Export Contract)
% from the total amount of the Export Contract
V. Importer (foreign buyer)
Commercial name of the importer:
Address:
City:
Postcode:
Identification No.:
State:
Legal form of the importer:
Predominant ownership form (state, private):
Main area of business activities:   
    
    
    
Bank of Importer:
Address:
City:
Postcode:
State:
Relations of importer to other subject or to an exporter:
(capital group, parent company, subsidiary, other relation)
Names of other subjects which are in capital relations to the importer:
1.
2.
3.
4.
5.
Your experience with the debtor and/or importer until now:
Total amount of your receivables against the debtor and/or 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 draw-down and repayment of the credit
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 "D" 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:
Statutory body:
Date:
Signature:   .......................................................................................
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