V Insurance Against the Risk of Inability to Fulfil an Export Contract Annex No. 5 – Statement of applicant for insurance on the form of securing of receivables under the Export Contract

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Annex No. 5
to application for insurance against the risk of impossibility to perform Export Contract – "V"
Statement of applicant for insurance on the form of securing of receivables under the Export Contract

  Name:
  Company registration number:
  Tax registration number:
  Registered office:
  Represented by:
as the Applicant for conclusion of insurance contract to insure against the risk of impossibility to perform Export Contract – V ("applicant") hereby declares that payment of applicant's receivables from the importer, which is , basedm  ("importer"), arising out of Export Contract concluded on  between the applicant and the importer ("Export Contract") is secured in the following manner (select one of the options below):
  Insurance contract No.:
  Dated:
  Name of the insurance company:
  Company registration number:
  Tax registration number:
  Registered office:
  Insurance contract No.:
  Dated:
  number of limit (if stated):
  amount of the limit in CZK:
  Name:
  Company registration number:
  Tax registration number:
  Registered office:
  Value of the letter of credit in CZK:
  Validity of the letter of credit:
  In       dated  
[person authorized to act for the applicant]
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