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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 I

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

I. Insured (Investor)

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. Foreign company (a company into which investment was made)

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

III. Calculation of incurred loss:

Description	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

Documentation evidencing the investment
Documentation proving cause of origination of a loss
Documentation on extent of incurred loss and its causes
Correspondence related to the investment under threat
Other attachments:

Number of attachments:

Date:

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

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