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Application for conclusion of an insurance contract

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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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APPLICATION

for insurance of a credit for financing of production for export against the risk of non-fulfilment of the credit resulting from of inability of the exporter to fulfil obligations from the Export Contract

GIC type F

Applicant / Insured:

Export Contract

Recipient of the credit:
Amount:
Credit length:

Export Contract

Subject:
to the country:
Purchase price:
Manufacturer:

Main suppliers:

Foreign Buyer:

Country:
Address:
The share of foreign deliveries exceeding 20% for one country:
Country:

I. Applicant

Commercial name of the bank:

Company Identification No.:

Tax registration No.:

Address:

City:

Postcode:

Legal form:

Banking connection:

Account number:

Name and position of the statutory representative:

Responsible person:

Phone:

Fax:

E-mail:

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

II. Credit for pre-export financing of production:

Credit contract No.

from

concluded with the company (debtor)

Commercial name:
Legal form:
Address:
City:
Postcode:
Company Identification No:

Credit amount

represents

% Amount of the Export Contract

extended for the period of

Starting point of credit:
Instalment deferral:
Number of instalments:

Principal:
Interest:
Fees:

Total

of insurance value

Form of securing the repayment of the pre-export credit:

Draw-down of credit:		Repayment of credit:
Date	Amount	Date	Amount

III. Export Contract

Subject of the Export Contract (goods and services):
Date of signing of the Export Contract:

Expected:
Starting date of deliveries:
Finishing date of deliveries:
Number of partial deliveries:

Amount 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:

Repayment term of the export credit:

years

months

Payment terms of the export credit:
(payment deferral, number and periodicity of instalments, interest rate, total amount of interest)

Form of securing the repayment of the export credit:

State of negotiations for insurance of the export credit with EGAP:

Definition of origination of the export receivable in the Export Contract:

IV. Debtor (Borrower of a credit for pre-export financing of the production):

Commercial name of debtor:
Address:
City:
Postcode:
Company Identification No:
Tax registration No.:
Legal form of the debtor:
Predominant capital ownership form (state, private):
Bank of debtor:
Banking connection:
Account number:
Address:
City:
Postcode:
Relations of debtor to other capital subject:
(capital group, parent company, subsidiary, other relation)

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

1.
2.
3.
4.
5.

Contact person of the debtor:
Phone:
Fax:
E-mail:

Mention all further data known to you regarding the requested insurance which could be related to risk assessment of the business transaction:

Please attach to the filled-in application:

Calculation formula
Declaration of Exporter on the share in the value of export
Schedule of draw-down of pre-export credit by expense items
Assessment of creditworthiness of a debtor by a bank (Applicant for insurance)
Documentation to assessment of a debtor in accordance with attachments to the application

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 "F" 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 agree to reimburse EGAP for expenses connected with assessment of insurance risk made on the basis of this application even if there was no concluded insurance promise contract or insurance contract; reimbursement will be in the extent of internal price directive of EGAP.

Attachments to the application:

Attachment No.1 - Form for declaration of the Exporter on the share in the value of export
Attachment No.2 - List of documents for EGAP's assessment

Commercial name of Applicant and position of the statutory representative:

Date:

Signature: .......................................................................................

Attachment No.1
Declaration of Exporter on share in the value of export

Exporter:

Commercial name:
Company Identification No.:
with seat:
represented by:

declares,

that the share of goods and services of Czech origin in the total value of export1), which is subject to insurance of export credit risks, shall be is at least % from the value of the export which isCZK and

accepts obligation

to inform the Export Guarantee and Insurance Corporation (hereinafter "export insurance company") on decrease in the share of goods and services of Czech origin in the total value of the export which has been stated in this declaration in case this decrease would be more than 5 % and to explain reasons for this change,
in case the share of goods and services of Czech origin in the total value of the export falls under 50%, to ask the export insurance company for a subsequent approval of the exception,
reimburse the export insurance company for damages by an amount equal to the indemnification paid as a result of non-fulfilment of mentioned criteria in case the Exporter has given untruthful data in the above-mentioned declaration or if it has been discovered later that in realization of the Export Contract the above-mentioned share was by more than 5 % lower than the share assumed by the insurance contract.

This declaration is an inseparable part of the application for insurance from ,
submitted
(Applicant for insurance)

Signature: .......................................................................................

Full name, signature and position of the person authorized to act on behalf of the Exporter:

Date:

1) the share of the export is calculated according to instruction for calculation of the share of goods and services of Czech origin in the total value of the export which is a part of this Declaration

Instruction for calculation of the share of goods and services of Czech origin in the total value of the export

The share of goods and services of Czech origin has to represent at least 50 % of the value of the export unless stated otherwise below.
Goods and service, which are subject of the export are considered as goods and services of Czech origin if following conditions are fulfilled:
1. Export Contract has been negotiated by the exporter who is a legal person with seat or a natural person with permanent residence on the territory of the Czech Republic or a foreign company who is controlled by a legal person having its registered seat on the territory of the Czech Republic and participating - directly or indirectly - in the basic capital of the foreign company by more than 50 %, or controlling the majority of voting rights related to the participation in the basic capital of the foreign company, or can appoint a majority of members of the Board of Directors, Supervisory Board or other similar managing body of the foreign company,
2. goods and services, which are subject of the export are invoiced by the Exporter (defined according to letter a) to a foreign buyer (importer),
3. a sub-delivery for the export is considered to be Czech if it has been delivered and invoiced to the Exporter by a sub-supplier who is a legal person with seat or a natural person with permanent residence on the territory of the Czech Republic (hereinafter Czech sub-supplier),
4. sub-deliveries (components, parts, material and such), bought by the Exporter or his Czech sub-supplier from abroad, are considered to be Czech ones only in case the Exporter or his Czech sub-supplier added value to these sub-deliveries in production (it cannot be pure re-export of goods in an unchanged state and the Exporter cannot be a mere trader whose share in the export is made by trade margin only); the Exporter and/or his Czech sub-supplier have to be able to prove (way of proving - e.g. comparison of payment for a sub-delivery with calculation of the final price of product in which the sub-delivery is included),
5. a sub-delivery from abroad which is a part of the Export Contract and for which EGAP obtained reinsurance from a foreign credit insurance company, has the same character for calculation of the share as Czech sub-deliveries even if it does not comply with criteria under letter d),
6. in case of insurance of an export credit and if the credit is financed from several sources, the sub-delivery from abroad which is a part of the Export Contract and which is financed without Czech state export support (i.e. without insurance by EGAP or without financing/refinancing by CEB, it has the same character as the Czech sub-delivery for purposes of the calculation even if it does not comply with criteria under letter d),
7. in case of insurance of a bank guarantee and when the foreign sub-delivery is covered by a counter guarantee, it has the same character as the Czech sub-delivery for purposes of the calculation even if it does not comply with criteria under letter d).
Sub-deliveries bought by the Exporter or his Czech sub-supplier from abroad which do not comply with conditions mentioned under par. 2, are considered for purposes of the calculation of the share of goods and services as foreign sub-deliveries.
Provisions on foreign sub-deliveries according to par. 2 letters d) through g) do not apply on sub-deliveries whichthe Exporter has bought from sub-suppliers in the country of final destination of the export. Such sub-deliveries represent local costs ; extent of insurance with state support for them is restricted by international rules.

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