V Insurance Against the Risk of Inability to Fulfil an Export Contract Application for Insurance Against the Risk of Inability to Fulfil an Export Contract (GIC type V)

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APPLICATION
for Insurance Against the Risk of Inability to Fulfil an Export Contract
GIC type V
pursuant to Act No. 58/1995 Coll.1

1 Act No. 58/1995 Coll., on the Insurance and Financing of Exports with State Support and on the Supplement to Act No. 166/1993 Coll., on the Supreme Audit Office, as amended, as amended

  Applicant for insurance:
  Export Contract:
  Subject:
  To country:
  Manufacturer:
  Total export value2:
  Insurance value (value of expected
  possible losses):
  Total delivery time (in months):

2 price agreed in the Export Contract

I. Applicant for insurance: (exporter)
  Name:
  Company registration number:
  VAT ID No.:
  File number in Business Register:
  Registered office:
  Address for postal service:  
     Street
     City
     Post code
  Legal form:
  Applicant's bank:
  A/C No.:
  Persons authorized to sign for the company:
  Contact person:
  Telephone:
  Fax:
  E-mail:
  Tying the payment of benefit required:
  (If yes, identify the entity and bank details, including account number.)
  Form of reinsurance and securing of receivables under the Export Contract (select one of the below possibilities):
  Contract number:
  Limit:
  Valid until:
  Bank name:
  Amount of the letter of credit:
  Valid until:
  Insurance of credit to finance production for export against the risk of non-payment will be required:
II. Information about the exporter
  Number of employees:
  Annual turnover for the last accounting
  period:
  Relation of the exporter to other entities3:
Names of entities that are part of a group financially linked with the exporter3:
  1.
  2.
  3.
  4.
  5.

3 Financial group of an entity is a group of natural or legal persons, where:

  1. two or more natural or legal persons that, unless proven otherwise, constitute a single risk since one of them has direct or indirect control over the other person(s);
  2. two or more natural or legal persons between which there is not a relationship of control referred to in (a) but that must be seen as persons constituting a single risk because they are interconnected to such an extent that if one of them got into financial difficulties, mainly difficulties with funding or payback, the other person or all other persons would probably also get into difficulties with funding or payback,

control is understood as a relationship between the parent company and a subsidiary company (persons) where the controlling person (parent company):

  1. has a majority of voting rights of shareholders or members in the other company; or
  2. has the right to appoint or remove a majority of the members of the administrative, managing or supervisory body of the other company and is concurrently a shareholder or member of the company; or
  3. has the right to exercise a dominant influence on any company it is a shareholder or member of within the meaning of a contract concluded with it or pursuant to its constitution or memorandum of association where the law which governs the company allows that it is subjected to such contracts, constitution or memorandum of association; or
  4. is a shareholder or member of any other company and
    1. a majority of members of the administrative, managing or supervisory body of this company who were members of these bodies during the current and previous accounting period until the time of the preparation of the consolidated financial statements, were appointed solely using their voting rights, or a share in any other company is at least 20%; or
    2. exercises, based on an agreement concluded with other shareholders or members of this company, a majority of voting rights of shareholders and members in this company.

A group of natural or legal persons consisting of central government and all natural or legal persons directly or indirectly controlled by it or interconnected as referred to in (b) are not considered a financially linked group.

The existence of a financially linked group made of a central or regional government or local bodies ("central bodies") and other natural or legal persons may be assessed separately for each person directly controlled as referred to in (a) or directly interconnected as referred to in (b) or all natural and legal persons that are controlled by this person as referred to in (a) or interconnected with this person as referred to in (b), including central bodies.

III. Export contract
  Subject-matter of the Export Contract
  (goods and services):
  The Export Contract was concluded   on 
 - state the state of negotiations:
  Conditions of effect under the Export Contract:
  Expected date of commencement of
 deliveries:
  Expected date of termination of deliveries:
  Expected number of sub-deliveries:
  Total export value2
  (in the currency of the Export Contract):
Delivery parity  (under INCOTERMS) from year: 
Payment terms of the Export Contract:
  Down payment (advance payment)   %, i.e. in the currency
  of the Export Contract: 
  Payments on delivery   %, i.e. in the currency
  of the Export Contract: 
  Deferred maturity of export receivable 
  (export credit) 
 %, i.e. in the currency
  of the Export Contract: 
  Period of repayment of the export receivable (export credit):   years and   months
  Other conditions of the export credit (deferment of payments, number and frequency of repayments):
  Form of recouping the export credit:
  Calculated profit   %, i.e. in the currency
  of the Export Contract: 
  Moment of rise of receivable under the
  Export Contract:
  a) Obligations of the exporter and sanctions for their non-fulfilment under the Export Contract
  b) Obligations of the importer and sanctions for their non-fulfilment under the Export Contract
  c) Form of recouping the purchase price (guarantees, bills of exchange, letters of credit, etc.)
  d) Other proposed conditions to the export contracts, namely the importer's liability to submit documents necessary for
its financial evaluation and the financial evaluation of the guarantors, i.e. mainly financial statements of the debtor
and guarantor
  Number of jobs created in the CR by
  the export
  Number of jobs maintained in the CR by
  the export
National percentage values:
 Main subcontractors (manufacturers):
  1. Sub-deliveries from contractors based in the Czech Republic4
    1. Name:
        Delivery value:  thousand  
 (in the currency of the Export Contract)
 % of the total export value
    2. Name:
        Delivery value:  thousand  
 (in the currency of the Export Contract)
 % of the total export value
  In case of need add other important subcontractors
    Percentage value of Czech deliveries on the total export value: 
  2. Percentage value of local deliveries in the importer's country5 in the total export
      thousand  
      (in the currency of the Export Contract)
      % of the total export value
  3. Sub-deliveries from third countries outside the country of import4
    1. Country:
        Name:
        Delivery value:  thousand  
 (in the currency of the Export Contract)
 % of the total export value
    2. Country:
        Name:
        Delivery value:  thousand  
 (in the currency of the Export Contract)
 % of the total export value
  In case of need add other important subcontractors
    Percentage value of sub-deliveries from third countries on the total export value: 

2 price agreed in the Export Contract

4 Over 5% of the export value

5 costs of goods and services in the importer's country under the OECD Consensus

IV. Importer/debtor (foreign buyer)
  Name:
  Company registration number:
  VAT ID No.:
  Registered office:
  Address for postal service:  
     Street
     City
     Country
  Legal form:
  Predominant form of ownership
  (state, private):
  Main field of activities:


  Importer's bank:
  Registered office:
  Address for postal service:  
     Street
     City
     Country
  Relation of the importer to other entities3:
Names of entities that are part of a group financially linked with the importer3:
  1.
  2.
  3.
  4.
  5.
  Your experience with the debtor or importer so far:
  The amount of your receivables from the debtor/importer (in thousands CZK):
  Of which overdue:

3 Financial group of an entity is a group of natural or legal persons, where:

  1. two or more natural or legal persons that, unless proven otherwise, constitute a single risk since one of them has direct or indirect control over the other person(s);
  2. two or more natural or legal persons between which there is not a relationship of control referred to in (a) but that must be seen as persons constituting a single risk because they are interconnected to such an extent that if one of them got into financial difficulties, mainly difficulties with funding or payback, the other person or all other persons would probably also get into difficulties with funding or payback,

control is understood as a relationship between the parent company and a subsidiary company (persons) where the controlling person (parent company):

  1. has a majority of voting rights of shareholders or members in the other company; or
  2. has the right to appoint or remove a majority of the members of the administrative, managing or supervisory body of the other company and is concurrently a shareholder or member of the company; or
  3. has the right to exercise a dominant influence on any company it is a shareholder or member of within the meaning of a contract concluded with it or pursuant to its constitution or memorandum of association where the law which governs the company allows that it is subjected to such contracts, constitution or memorandum of association; or
  4. is a shareholder or member of any other company and
    1. a majority of members of the administrative, managing or supervisory body of this company who were members of these bodies during the current and previous accounting period until the time of the preparation of the consolidated financial statements, were appointed solely using their voting rights, or a share in any other company is at least 20%; or
    2. exercises, based on an agreement concluded with other shareholders or members of this company, a majority of voting rights of shareholders and members in this company.

A group of natural or legal persons consisting of central government and all natural or legal persons directly or indirectly controlled by it or interconnected as referred to in (b) are not considered a financially linked group.

The existence of a financially linked group made of a central or regional government or local bodies ("central bodies") and other natural or legal persons may be assessed separately for each person directly controlled as referred to in (a) or directly interconnected as referred to in (b) or all natural and legal persons that are controlled by this person as referred to in (a) or interconnected with this person as referred to in (b), including central bodies.

V. Description of the business case
 Include a description of the business case here, i.e. a detailed description of the subject of export or the project, as the case may be, and its funding; references to similar projects of the exporter in terms of the territory of final destination of the export; how the exporter or the funding bank was contacted with the business case, whether the parties to the transaction (funding of the project) are known to the exporter or the bank from previous business cases or completely new, what are the benefits of the project for the exporter (to strengthen its position in the market, to enter a new market, to maintain an existing business relationship, etc.), for the funding bank and for the Czech Republic, what the main expectable risks are and how such risks can be addressed in a practical manner.
Provide any other specific information known to you regarding the required insurance which could be related to the assessment of risk of the business case and to the importer, including your experience with the performance of the contract and adherence to payment terms.
The following annexes are an integral part of this form:
Annex No. 1 -  Basic terms and conditions of insurance against the risk of impossibility to perform Export Contract "V"
Annex No. 2 -  Calculation of expected production costs entered for insurance broken down by type of cost
Annex No. 3 -  Exporter's statement on the export value percentage
Annex No. 4 -  Exporter's declaration on compliance with legal provisions against bribery in international trade and in prosecution of the exporter
Annex No. 5 -  Statement of applicant for insurance on the form of securing of receivables under the Export Contract
Annex No. 6 -  Overview of submitted documents for analysis
All information is confidential and is used by Exportní garanční a pojišťovací společnost, a.s. (Export Guarantee and Insurance Corporation) only for the decision on the provision of insurance and the preparation of a draft insurance contract (contract on the promise of insurance). Exportní garanční a pojišťovací společnost, a.s. (Export Guarantee and Insurance Corporation) reserves the right to request the submission of other information and documents necessary for the assessment of the application for insurance and for taking out the insurance.
Statement of the applicant for insurance
Against the Risk of Inability to Fulfil an Export Contract – „V“
I declare that:
  1. I have acquainted myself with the General Insurance Terms and Conditions of type "V" and basic terms and conditions of insurance Against the Risk of Inability to Fulfil an Export Contract listed in Annex 1, and I confirm that the information stated in this application and its annexes is correct and complete and no important facts known as of the date of filing this application for insurance have been omitted or withheld and are not in conflict with the basic terms and conditions of insurance and the General Terms and Conditions of type "V",
  2. I have acquainted myself with the information on personal data processing by the insurer for the purposes of insurance listed on the insurer's website,
  3. the above business case for the insurance of which I am applying is, based on preliminary assessment, feasible in terms of its structure and financial health of all the stakeholders, and that I have a serious intent to further negotiate the provision of insurance of this business case, and
  4. I have the consent of all the stakeholders to provide information and documents listed in the submitted application, its annexes and where other material is necessary to assess the application for insurance and to take out insurance, I will request such consent.
I agree to immediately inform the insurer of any additional facts and changes applicable to or related to the requested insurance which occur after submitting this application.
I agree with the provision of data, information and documents provided by me and handed over to the insurer in connection with and regarding insurance to persons providing the insurer with information and assessment and bodies of the company of the insurer including shareholder representatives, and I agree with the provision of such data, information or documents to the respective bodies and persons if provided so by applicable legislation, and with their provision to a reinsurance company and third parties to the extent necessary for negotiations on the conclusion of an insurance contract and for its conclusion.
  Name of the applicant:
  Person(s) authorized to act for the applicant:
  In      dated 
[Signature of person(s) authorized to act for the applicant]
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