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If Страхование кредита на инвестиции за рубежом Application for conclusion of an insurance contract

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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?
 
 
  The company which is subject of investing is:
 
 
  Will there be participation of the host state in the company?
 
      %
  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:
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 request:  
   
   
   
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:   .......................................................................................
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