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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 prospection of foreign markets

GIC type P

I. Prospection

Subject of prospection (goods, services):
in the countries:

II. Applicant

Commercial name of the applicant:

Company Identification No.:

Tax registration No.:

Address:

City:

Postcode:

Legal form:

Number of employees of the company:

Annual turnover for the last accounting period:

Balance sum for the last accounting period:

Banking connection:

Account number:

Name and position of the statutory body:

Responsible person:

Phone:

Fax:

E-mail:

Assignment of the indemnification required:

yes no

(If yes, state the identification of the subject and bank connection including the account number.)

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

III. Prospection expenses

Prospection expenses in total
of which:
costs of advertising, promotion and of promotional materials
costs connected with participation in commercial campaigns abroad with the exception of the traveling expenses and accommodation
costs for export and marketing consulting included analysis
costs of legal services abroad
storage costs abroad
costs of certification of products on the market for prospection
costs for establishment and operation of a representation of the exporter abroad

IV. National contents

Main suppliers (manufacturers):
1. Czech Republic, commercial name:

Delivery value:

thous.

(in currency of the Export Contract)

% from the total amount of the Export Contract

2. State:

Commercial name:

Delivery value:

thous.

(in currency of the Export Contract)

% from the total amount of the Export Contract

3. State:

Commercial name:

Delivery value:

thous.

(in currency of the Export Contract)

% from the total amount of the Export Contract

Inseparable parts of this form are attachments:
Attachment No.1 - Prospection Plan in detail
Attachment No.2 - Prospection Budget containing estimated expenses and revenues from the export to the foreign market. The budget cannot be loss-making.

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 "P" 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 take notice of my duty to reimburse the insurer all expenses accrued in connection with verification of the insurance risk also in case the insurance contract (insurance promise contract) will be prepared on the basis of data entered in this form and the contract will not be signed.

Insurance of export credit risks with state support cannot be given to exports which were negotiated by way of bribery in international trade in the sense of the § 160 and subsequent of the Criminal Code. For these purposes, I declare on behalf of our company and on behalf of persons representing our company that there has been and there will be no breach of rules against bribery in international trade 1). In this relation I further declare that persons acting on behalf of our company or representing our company were not charged by the criminal offence of bribery and they had not been convicted of such criminal offence in last 5 years. Furthermore, I declare that that our company has not been mentioned in the publicly accessible debarment list of the World Bank Group.

I accept that the insurer has the right to verify truthfulness of the above-mentioned declaration and obligate myself to submit all information and documentation the insurer may request in this regard.

According to Art. IX. Of the GIC P, the insurer has the right to refuse indemnification if it has been proven that the applicant entered into the application for insurance incomplete or untruthful data with regard to bribery in international trade.

¹⁾ Communication of the Ministry of Foreign Affairs No. 25/2000 Coll. of international treaties) on acceptance of Convention on Combating Bribery of Foreign Public Officials in International Business Transactions (part 13/2000 of the Collection of international treaties circulated on March 29, 2000).

Commercial name of the applicant:
Name and position of the statutory body:
Date:
Signature: .......................................................................................

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