Form EIB 07-01A, Sectio EIB 07-01A, Sectio Electronic Claim Filing System, Short-Term Insurance

Page 1 of 1

Claim Control No.:
(Draft)

Short-term Multi-buyer Policy Claim
Section I - Certification

( * An asterisk denotes that a field is a required entry)

Please Note that the certification is subject to penalties as provided in Article 18 U.S.C. Sec. 1001
On behalf of the Insured, I certify that I have examined the information included in this Electronic Claim Payment Application and certify that
the amount claimed is presently owing by the buyer/issuing bank; the buyer has not asserted any defenses to this debt nor disputed the amount
of the debt owing, there are no unresolved documentary credit disputes between the Insured and the issuing bank on any insured transaction;
the Insured has not granted any discounts, allowances, rebates or commissions, and has not made any payments to the buyer/issuing bank; to
the best of its belief, the Insured has complied with the terms and conditions of the policy, all the information supplied in support of this claim
is complete and true, and the Insured has not withheld any material facts; the rates of interest charged are legally valid and enforceable for the
approved currency under the laws of the country of the buyer/issuing bank.
Under penalty of perjury, I declare that the information I have hereby submitted on-line, to the best of my knowledge and belief, is
true, complete and correct.
Certifier is the:
Certifier's Name
Company
Street Address
City
State
Zip Code
Phone Number

Insured

Assignee

Broker

Other

*
*
*
*
*
*
*

Fax Number
Email Address
Submit Claim
EIB 07-01A
The applicant is hereby notified that information requested by this form is done so under authority of the Export-Import Bank Act of 1945, as
amended (12 USC 635 et. seq.); provision of this information is mandatory and failure to provide the requested information may result in ExIm Bank being unable to determine eligibility for support. Ex-Im Bank may not require the information and applicants are not required to
provide information requested in this application unless a currently valid OMB control number is displayed on this form.
Public Burden Statement: Reporting for this collection of information is estimated to average 1 hour per response, including reviewing
instructions, searching data sources, gathering information, completing, and reviewing the application. Send comments regarding the burden
estimate, including suggestions for reducing it, to Office of Management and Budget, Paperwork Reduction Project OMB# 3048, Washington,
D.C. 20503.

https://apps.exim.gov/apps/ecfs/ecfsprod.nsf/FormStMB1SectionI?openform

8/23/2007