Insurance products »

Insurance of a Credit for the Financing of Investments of Czech Legal Persons in Foreign Countries »

Application for conclusion of an insurance contract

How to work with the form?

Enter your E-mail address in the corresponding field in the upper part of the form.
Before finishing the work, save entered data by clicking on "SAVE" in the upper part of the form.
The person saving the form as the first one becomes its administrator and receives 2 internet addresses of the form by an E-mail. The administrator may give the second address to other users.
The form can be filled in only by one user at a time.
The form registers all changes in the form of revisions differentiated by colour.
The administrator is automatically alerted by an E-mail on changes made by other user.
Revisions can be accepted by the administrator only.
Protocol of individual revisions can be obtained by clicking on the corresponding colour field.
For printing, use only a print form after clicking on "OK" at the end of the form.
In case of queries, contact please Mr. Vlastimil Nesrsta, phone +420 222 842 015, GSM: +420 724 761 444, E-mail: nesrsta@egap.cz

E-mail:

By selecting "Save", data input will be recorded.

APPLICATION

for insurance of a credit extended in relation with investment of Czech legal persons
abroad against the risk of non-payment of the credit

GIC type If

I. Applicant (Insured/Policyholder)

Commercial name:
Address:
Company Identification No:
Legal form:
Banking connection:
Account number:
Statutory body:
Name of a responsible person:
Name and position:
Phone:
Fax:
E-mail:

II. Investor:

Commercial name:
Address:
Company Identification No:
Legal form:
Banking connection:
Statutory body:
Name of a responsible person:
Name and position:
Phone:
Fax:
E-mail:

III. Foreign company

Commercial name:
Address:
Company Identification No:
Legal form:
Banking connection:
Statutory body:
Share owned by the investor:
Other owners of the foreign company and their shares:
Way how the investor controls the foreign company:
Date of establishment of the company:
Area of business activities:

IV. Localization of project:

City:
State:

V. Description of project

Brief characteristics of investment intention (intention, current development, prediction, products and services to be generated)

The total sum already invested by the investor (in CZK):
Of which the investment into the basic capital of the foreign company:
Loan to a foreign company:

Sources of financing of the investment (in CZK)
Of which own resources:
Credit:
Other sources: (please specify)

Is there a permit from authorities of the host state for establishment of this investment?

yes
no

The company which is subject of investing is:

new
it already exists - it is further development

Will there be participation of the host state in the company?

no
yes, it will be owned%

Expected duration of the investment:

VI. Investment credit

Credit amount:

i.e.

% from the amount of the investment

Attribution:
Interest:
Fees:

Total value requested for insurance:
Credit length:
Purpose of the credit:
Debtor of the credit for investment will be:	investor foreign company

VII. Draw-down and repayment schedule of the credit:

Draw-down		Repayment
Period:	Amount	Period:	Amount

Instalment deferral:
Periodicity of instalments:

VIII. Requested extent of cover

Additional insurance of political risks:	We do not require
We request:	Inability of conversion and/or transfer of returns
	Expropriation
	Politically motivated violence
	Breach of contractual obligations

IX. Guarantees for the credit for investment

Specify please individual planned guarantee instruments

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 "If" 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.

Please attach to the filled-in application:

business plan of the investment or a feasibility study
further documentation to assessment of the investment according to the list of EGAP
extract from the company register of the investor and of foreign company where the investment is to be directed
questionnaire for assessment of environmental impact of the investment and the declaration of the Investor (Attachment No. 1).
This questionnaire and this declaration are inseparable parts of this application
Declaration of the Investor on compliance on compliance with legal provisions against bribery in international trade. (Attachment No. 2)

Commercial name of Applicant and position of the statutory representative:

Date:
Signature:	.......................................................................................

By selecting OK you can access form in the printing format.

Site Map

+420 222 841 111