E Insurance of confirmed letter of credit Application for insurance of confirmed letter of credit (GIC type E)

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APPLICATION
for insurance of confirmed letter of credit
GIC type E
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

1) Applicant for insurance
  Name:
  Company registration number:
  VAT ID No.:
  File number in Business Register:
  Registered office2:
  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:
2) Exporter
  Name:
  Company registration number:
  VAT ID No.:
  Registered office2:
  Address for postal service:  
     Street
     City
     Post code
  Legal form:
  Number of employees3:
  Annual turnover for the last
  accounting period3:
  Balance sheet total for the last
  accounting period3:
3) Reference number of the letter of credit
4) Issuing bank
  Name:
  Company registration number4:
  VAT ID No.:
  Registered office:
  Address for postal service:  
     Street
     City
     Country
  Relation to other entities5:
5) Amount of the letter of credit
  Amount  in currency 
  Amount charged by the bank for confirming the letter of credit 
6) Insurance value
  Amount  in currency 
7) Payment terms of the letter of credit
  Deferment of payments  days
8) Date of opening the letter of credit
9) Date of confirmation of the letter of credit
10) The deadline for presentation of documents / validity of the letter of credit
11) Expected date of payment of the letter of credit
12) 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 value6
  (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: 
  Amount of deferred payment   %, i.e. in the currency of the Export Contract: 
  Other payments   %, i.e. in the currency of the Export Contract: 
  „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“
National percentage values:
Main subcontractors (manufacturers):
    1. Czech Republic/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
    3. 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 Czech deliveries on the total export value:
    Number of jobs created in the CR
by the export
    Number of jobs maintained in the CR
by the export
13) Importer
  Name7:
  Company registration number5:
  Registered office:
  Address for postal service:  
     Address
     City
     Country
  Legal form:
  Predominant form of ownership
  (state, private):
  Main field of activities:


  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.

2 head office – full address of the registered office in accordance with a public register

3 fill out in accordance with the definition of small and medium-sized enterprises listed in Annex I to the Commission Regulation (EC) No 800/2008 of 6 August 2008 declaring certain categories of aid compatible with the common market in application of Articles 87 and 88 of the Treaty (General block exemption Regulation)

4 if the registration number is maintained in a public or similar register in the country of the entity's registered office

5 A financially linked group is understood as a group of natural or legal persons where:

  1. two or more natural or legal persons that, unless proven otherwise, constitute a single risk since one of them has direct or indirect control over the other person(s);
  2. two or more natural or legal persons between which there is not a relationship of control referred to in (a) but that must be seen as persons constituting a single risk because they are interconnected to such an extent that if one of them got into financial difficulties, mainly difficulties with funding or payback, the other person or all other persons would probably also get into difficulties with funding or payback;

control is understood as a relationship between the parent company and a subsidiary company (persons) where the controlling person (parent company):

  1. has a majority of voting rights of shareholders or members in the other company; or
  2. has the right to appoint or remove a majority of the members of the administrative, managing or supervisory body of the other company and is concurrently a shareholder or member of the company; or
  3. has the right to exercise a dominant influence on any company it is a shareholder or member of within the meaning of a contract concluded with it or pursuant to its constitution or memorandum of association where the law which governs the company allows that it is subjected to such contracts, constitution or memorandum of association; or
  4. is a shareholder or member of any other company and
    1. a majority of members of the administrative, managing or supervisory body of this company who were members of these bodies during the current and previous accounting period until the time of the preparation of the consolidated financial statements, were appointed solely using their voting rights, or a share in any other company is at least 20%; or
    2. exercises, based on an agreement concluded with other shareholders or members of this company, a majority of voting rights of shareholders and members in this company.

A group of natural or legal persons consisting of central government and all natural or legal persons directly or indirectly controlled by it or interconnected as referred to in (b) are not considered a financially linked group.
The existence of a financially linked group made of a central or regional government or local bodies ("central bodies") and other natural or legal persons may be assessed separately for each person directly controlled as referred to in (a) or directly interconnected as referred to in (b) or all natural and legal persons that are controlled by this person as referred to in (a) or interconnected with this person as referred to in (b), including central bodies.

6 price agreed in the Export Contract

7 exact name as in the entity's country of registration and in the language in which it will be stated in the Credit Contract

The following annexes are an integral part of this form:
Annex No. 1 -  Basic terms and conditions of insurance of confirmed letter of credit “E”
Annex No. 2 -  Exporter's statement on the export value percentage
Annex No. 3 -  Exporter's declaration on compliance with legal provisions against bribery in international trade and in prosecution of the exporter
Annex No. 4 -  Current annual report of the issuing bank including an analytical statement prepared by the applicant for insurance (bank)
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
I declare that:
  1. I have acquainted myself with the General Insurance Terms and Conditions of type "E" and basic terms and conditions of insurance of a Confirmed Letter of credit 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 "E",
  2. I have acquainted myself with the information on personal data processing by the insurer for the purposes of insurance listed on the insurer's website,
  3. the above business case is, based on preliminary assessment by the applicant for insurance, 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
  4. 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, i.e. Exportní garanční a pojišťovací společnost a.s. (Export Guarantee and Insurance Corporation), 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]

8 persons involved in the export (transaction) and its financing

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