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Notification of a threat of an insurance loss

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NOTIFICATION OF A THREAT OF AN INSURANCE LOSS

GIC type V

Insurance Contract number:
Insurance Decision number (for framework contracts):
Cause of an insurance loss according to GIC V Art. VII.:
Supplementary insurance of exchange rate risk (for contracts before December 31, 2006): yes no
Export Contract cancelled: yes no

I. Insured (Exporter)

Commercial name:
Company Identification No.:
Seat:
Phone:
Fax:
E-mail:
Contact Person:
Bank Connection:
Authorised Person 1):

1) Person for whom the right to indemnification comes into existence as a result of an insurance loss - to be filled in only if it is other person than the insured

II. Debtor (Importer)

Commercial name:
Seat:
State:
Debtor:	Private Public
Phone:
Fax:
E-mail:
Contact Person:
Bank Connection:

III. Data on a threat of an insurance loss:

Description of incurred expenses (according to state of processing of production for realization of the Export Contract)	Amount

Share of goods of Czech origin in the total export exceeds 50%:

yes no

IV. Commentary:

Description of business transaction:

Reasons and circumstances leading to a threat of an insurance loss (must be filled-in):

Following steps have been made for recovery/ensurance of the receivable (must be filled-in):

V. Instruction

the form has to be duly filled-in and signed by a person authorized to act outwardly on behalf of the company
the insured will continue in all necessary measures in cooperation with the insurer to prevent origination of an insurance loss or to lower its extent
the insurer has the right to take all necessary measures in cooperation with the insured or independently leading to prevention of an insurance loss or to lowering of its extent

VI. Attachments

Export Contract
Correspondence with the importer
Permits for transfer of goods or services and export licences (if required)
Documentation on extent of material damage and on circumstances causing it

Number of attachments:

Date:

Signature of insured:	.....................................................................................

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