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Z Страхование экспортных банковских гарантий Application for conclusion of an insurance contract

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APPLICATION
for insurance of a bank guarantee issued in relation to conditions for winning or fulfilment of the Export Contract
GIC type Z
  Type of guarantee:
 
 
 
  Applicant / Insured:
 Export Contract
  Subject:
  To the Country:
  Amount of the Export Contract:
  Payment and credit terms:
  Validity of the Export Contract:
  Length of the Export Contract (in months):
  Manufacturer:
  Address:
  Company Identification No.:
 Foreign Buyer:
  Country:
  Address:
  The share of foreign deliveries exceeding 20% for one country:
  Country:
I. Insured
  Commercial name of the insured:
  Company Identification No.:
  Tax registration No.:
  Address:
  City:
  Postcode:
  Legal form:
  Banking connection:
  Account number:
  Statutory body:
  Responsible person:
  Phone:
  Fax:
  E-mail:
  Applies for:
   
   
  Extent of cover:
   
II. Principal
  Commercial name of the Principal:
  Company Identification No.:
  Tax registration No.:
  Address:
  City:
  Postcode:
  Legal form:
  Banking connection:
  Account number:
  Statutory body:
  Contact person:
  Phone:
  Fax:
  E-mail:
III. Foreign Buyer
  Commercial name:
  Address:
  City:
  Postcode:
  Country:
  Legal form:
  Predominant capital ownership form:  
  Foreign buyer's bank:
  Address:
  City:
  Postcode:
  Country:
IV. Guarantee
  Type of guarantee:
  value of the guarantee in the currency of the Export Contract     currency  
  i.e.     % of the Export Contract
  Other supplementary data:
  Validity of the guarantee:
  Requested duration of insurance:
  Governing law in the wording of guarantee:
  Arbitration:
  Beneficiary of the guarantee:
  Address:
  City:
  Postcode:
  Country:
V. Export Contract:
  Subject of the Export Contract (goods and services):
  Date of signing of the Export Contract:
  Present state of the fulfilment of the Export Contract:
 Expected:
  Starting date of deliveries:
  Finishing date of deliveries:
  Number of partial deliveries:
  Amount of the Export Contract (in currency of the Export Contract):
  Delivery clause (according to INCOTERMS) from:
  Advance Payment %, i.e. in currency of the Export Contract:
  Cash Payment %, i.e. in currency of the Export Contract:
  Credit (Payment Deferral) %, i.e. in currency of the Export Contract:
  Repayment term of the export credit: years months
  Form of securing the repayment of the export credit:
  Sources of financing of the production for the Export Contract:
  Mention all further data known to you regarding the requested insurance which could be related to risk assessment of the business transaction:
An inseparable parts of this application is:
  • Declaration of the Exporter on the share in the value of export
  • for an advance payment bond: calculation of draw-down of the bond by items and dates
  • assessment of creditworthiness of the debtor by the applicant for insurance
  • documentation for assessment of the debtor according to the attached list
  • Declaration of the Principal on compliance on compliance with legal provisions against bribery in international trade. (Attachment No. 1)

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 that I am acquainted with General Insurance Conditions"Z" 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 the insurer 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 the insurer.

  Commercial name of the Applicant and Statutory Body:
  Date:
Signature:   .......................................................................................
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