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Insurance of a Confirmed Letter of Credit »

Notification of a threat of an insurance loss

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In case of queries, contact please Mr. Vlastimil Nesrsta, phone +420 222 842 015, GSM: +420 724 761 444, E-mail: nesrsta@egap.cz

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NOTIFICATION OF A THREAT OF AN INSURANCE LOSS

GIC type E

Insurance Contract number:
Insurance Decision number (for framework contracts):
Cause of an insurance loss according to GIC E Art. VII.:
Supplementary insurance of exchange rate risk (for contracts before December 31, 2006): yes no

I. Insured (bank confirming a Letter of Credit)

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. Issuing bank (bank of Importer issuing the Letter of Credit)

Commercial name:
Seat:
State:
Debtor:	Private Public
Phone:
Fax:
E-mail:
Contact Person:
Bank Connection:

III. Data on a threat of an insurance loss:

Receivable No.	Amount	Currency	Issued	Due	Interest	Partial payment	Net amount

Share of goods of Czech origin in the total export exceeds 50%:

yes no

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

Copy of the Letter of Credit and related documentation
Copies or photocopies of unpaid invoices
Customs and transportation documents related to unpaid receivables
Export Contract
Correspondence with the debtor related to unpaid receivables
Documentation on extent of material damage and on circumstances causing it
Other attachments:

Number of attachments:

Date:

Signature of insured:	.....................................................................................

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