Form EIB92-64 Application for Exporter Short-Term Single-Buyer Insuran

Export-Import Bank of the United States

OMB #3048-0018
Expire 7/31/09

APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE
This application is to be completed by an exporter (or a broker acting on its behalf) in order to obtain a short-term insurance policy
covering sales to a single foreign buyer. Repayment terms can be up to 360 days.
An online version of this application is available on Ex-Im Bank’s web site. Ex-Im Bank encourages customers to apply on line, as it
will facilitate our review and allow customers a faster response time. Additional information on how to apply for Ex-Im Bank
insurance can be found on Ex-Im’s web site http://www.exim.gov.
Send this completed application to Ex-Im Bank, 811 Vermont Ave., NW, Washington, D.C. 20571. Ex-Im Bank will also accept emailed pdf and faxed applications. Ex-Im Bank will not require the originals of these applications to be mailed. The application must
be PDF scans of original applications and all required attachments. (Fax number 202.565.3380, e-mail [email protected])

APPLICATION FORM
Applicant/Exporter
The applicant/exporter is the U.S. entity that contracts with the buyer for the sale of the U.S. goods and services.
Applicant legal name:

State:

Contact person:

Country:

Position title:

E-mail:

Street Address:

Phone:

City:

Zip Code:

Fax:

Broker (if applicable):
Name of Broker:
Ex-Im Bank Broker#:
Contact Person:
Fax:
E-mail:
1. GENERAL QUESTIONS
A. Type of Coverage Requested
Comprehensive risk
Political risk
B. Qualification for Coverage
Will the applicant have title to the products at the time they are shipped?
Yes

No

Will the applicant directly invoice the buyer?
Yes

No

If you answered no to either, you may not be eligible for coverage. Call Ex-Im Bank or your broker for assistance.

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APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE
C. Primary Reason for applying for this policy
Risk mitigation
Financing
To offer more competitive terms

D. Is this a resubmission of a previously withdrawn, returned or denied application, or a follow-on policy for the same buyer?
Yes
No
If yes, indicate previous transaction number: _________________
E. Primary point of contact for this application
Exporter
Broker
2. SPECIAL COVERAGES
Check the boxes for the special coverage that apply to this transaction. Complete and attach the requested forms, where applicable.
Pre-shipment Cover
Attachment II – Pre-shipment
questionnaire required

Shipment to address in US

Bulk agriculture

Warehouse
Attachment V – Warehouse information
required

Additional Named Insured
Attachment IV - ANI required

Enhanced assignment
Attachment III - EA questionnaire
required

Services

Foreign currency coverage
indicate currency:____
- currency of supply contract
US dollar
foreign currency

Other

3. PARTICIPANTS
Provide information on the additional participants to the transaction.
Supplier
The supplier is the U.S. entity that manufactures the goods and/or performs the services to be exported. Check
various:
the supplier and there are no additional suppliers. Enter any additional suppliers, or check
Supplier legal name:

State:

Contact person:

Country:

Position title:

E-mail:

Street Address:

Phone:

City:

Postal Code:

Fax:

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if the exporter is

OMB #3048-0018
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APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE
Buyer
The buyer is the entity that contracts with the exporter for the purchase of U.S. goods and services.
Buyer legal name:

State:

Contact person:

Country:

Position title:

E-mail:

Street Address:

Phone:

City:

Postal Code:

Fax:

Guarantor
The guarantor is the person or entity that agrees to repay the credit if the buyer does not. Refer to the Short-Term Credit Standards to
determine in what circumstances personal or corporate guarantors are required.
No
Is a guarantor involved in this transaction? Yes
an individual or
a company?
If yes, is the guarantor
Guarantor legal name:

State:

Contact person:

Country:

Position title:

E-mail:

Street Address:

Phone:

City:

Postal Code:

Fax:

End-user
The end-user is the foreign entity that uses the U.S. goods and services:
Check if the end-user is also the buyer.
End-user legal name:

State:

Contact person:

Country:

Position title:

E-mail:

Street Address:

Phone:

City:

Postal Code:

Fax:

Agent
An agent is a business entity or individual located in the country of the borrower or buyer who has assisted in the sourcing, packaging,
and/or preparation of a request for support from Ex-Im Bank, and which will receive compensation in some form for their services.
Is an agent involved in this transaction? Yes

No

If yes, add the agent information below:
Agent legal name:

State:

Contact person:

Country:

Position title:

E-mail:

Street Address:

Phone:

City:

Postal Code:

Fax

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APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE

OMB #3048-0018
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Related Parties
Describe any direct or indirect ownership or family relationship that exists between any of the participants. If none, so indicate:
None.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Primary Source of Repayment
The PSOR is the entity whose financial statements or credit information form the basis of Ex-Im Bank’s evaluation of reasonable
assurance of repayment, i.e. the entity whose financial statements Ex-Im Bank uses to supply calculate the ratios for Short-Term
Credit Standards compliance. For this transaction, indicate whether the PSOR is:
the buyer,
the corporate guarantor, or
business combination, (e.g. the consolidated or combined financial statements of the buyer and one or more corporate guarantors.).
Indicate which entities comprise the combination___________________________________________________________________
No

Is the PSOR a financial institution?

Yes

Select the risk category of the PSOR:

Private sector

Does the PSOR have a bond rating?

Yes

Public sector

No

If yes, indicate the name of the rating agency, rating, and the date of the rating.
___________________________________________________________________________________________________________
4. TRANSACTION DESCRIPTION AND ELIGIBILITY
Indicate whether the sale represents a:
Firm order
sale in negotiations
response to an invitation to bid
Provide a description of the products or service, including their NAICs code, if known:
____________________________________________________________________________________________________
Regarding the above products or services…
No
Is each product produced or manufactured in the United States?
Yes
Has at least one-half of the value, exclusive of mark-up, been added by labor or material exclusively of United States origin?
No
Yes
No
Are these products on the munitions control list?
Yes
Used
Are the products new or used?
New
No
Are the products capital goods that will be used to produce exportable products? Yes
Will any value be added to the product after export from the U.S.?

Yes

No

If yes, provide an explanation: ________________________________________________________________________________
Has this transaction been considered by any other export credit insurer?

Yes

No

If yes, provide details: _______________________________________________________________________________________

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APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE
OMB #3048-0018
Expire 7/31/09

5. FINANCED AMOUNTS AND STRUCTURE
Enter the %s for each payment term the exporter will extend to the buyer
(e) Payment terms requested
Payment Type

(number of days)
Sight

Up to
30

Up to
60

Please check applicable box
Up
Up
Up to
Up to
to
to
90
270
120 180

Up to
360

Cash Against Documents (CAD)
Sight Draft Documents Against Payment (SDDP)
Unconfirmed Irrevocable Letter of Credit (UILC)
Open Account
Sight Draft Documents Against Acceptance (SDDA)
Promissory Note

single
multiple under one sales contract
Number of shipments:
Expected date(s) of shipment: _________________________________________________________________________
Estimated shipment volume to be insured: _______________________________________________________________
If multiple shipments, the expected highest amount outstanding during the shipment period: ________________________
Other security available: _____________________________________________________________________________
6. CREDIT INFORMATION ON THE PSOR
The information requested in Attachment I: Credit Information is attached.
7. NOTICES AND CERTIFICATIONS
Certifications
The applicant certifies that neither it, nor its Principals, have within the past 3 years been a) debarred, suspended, declared ineligible
from participating in, or voluntarily excluded from participation in, a Covered Transaction, b) formally proposed for debarment, with a
final determination still pending, c) indicted, convicted or had a civil judgment rendered against it for any of the offenses listed in the
Regulations, d) delinquent on any substantial debts owed to the U.S. Government or its agencies or instrumentalities as of the date of
execution of this application; or e) the undersigned has received a written statement of exception from Ex-Im Bank attached to this
certification, permitting participation in this Covered Transaction despite an inability to make certifications a) through d) in this
paragraph.
The applicant further certifies that it has not and will not knowingly enter into any agreements in connection with the Goods and
Services with any individual or entity that has been debarred, suspended, declared ineligible from participating in, or voluntarily
excluded from participation in a Covered Transaction. All capitalization terms not defined herein shall have the meanings set forth in
(1) the Export-Import Bank’s Non-procurement Debarment and Suspension regulations, 2 C.F.R. Part 3513, adopting by reference, the
OMB Guidelines to Agencies on Government wide Debarment and Suspension (Non-procurement), 2 C.F.R. Part 180; and (2) the
Debarment, Suspension, and Ineligibility provisions of the Federal Acquisition Regulation, 48, C.F.R. Subpart 9.4.
In addition, the applicant further certifies that it has not, and will not, engage in any activity in connection with this transaction that is
a violation of a) the Foreign Corrupt Practices Act of 1977, 15 U.S.C. 78dd-1, et seq. (which provides for civil and criminal penalties
against individuals who directly or indirectly make or facilitate corrupt payments to foreign officials to obtain or keep business), b) the
Arms Export Control Act, 22 U.S.C. 2751 et seq., c) the International Emergency Economic Powers Act, 50 U.S.C. 1701 et seq., or d)
the Export Administration Act of 1979, 50 U.S.C. 2401 et seq.; nor been found by a court of the United States to be in violation of any
of these statutes within the preceding 12 months, and to the best of its knowledge, the performance by the parties to this transaction
of their respective obligations does not violate any other applicable law.
The applicant certifies that the representation made and the facts stated in this document and any attachments are true, to the best of its
knowledge and belief, and it has not misrepresented or omitted any material facts, and if any of the certifications made herein become
untrue, Ex-Im Bank will be promptly informed of such changes. The applicant further understands that these certifications are subject
to the penalties for fraud against the U.S. Government (18 USC 1001, et seq.).
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Notices
The applicant is hereby notified that information requested by this application 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 Ex-Im Bank being unable to determine eligibility for support. The information provided will be reviewed to
determine the participants’ ability to perform and pay under the transaction referenced in this application. 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 (see upper right of each page).
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#
3048-0009, Washington, D.C. 20503.

Applicant (Exporter) name: __________________________________________________________________________________
Name and title of authorized officer:___________________________________________________________________________
Signature of Authorized officer:_______________________________________________________________________________
Date:____________________________________________________________________________________________________

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APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE

OMB #3048-0018
Expire 7/31/09

Attachment I: Credit Information Requirements
Directions: The required credit information depends on whether the PSOR is the buyer or corporate guarantor, or a financial institution
guarantor and on the amount of credit support requested. Check the boxes that are applicable to your transaction.
1.

The PSOR is not a financial institution:
a) Provide details of the exporter’s experience with the buyer
Does the exporter have any experience selling to the buyer?
If yes, provide the following information:
Date of first sale to the buyer: ______
Date of first credit sale to the buyer: ______
Historic credit experience with the buyer:
Yearly Credit
Experience
Total amount sold
Total amount on credit
Highest amount
outstanding for which
exporter has been paid
Payment terms/tenor

Current year

Yes

No

Prior year 1

Prior year 2

Amount now owing: ______________________________________________________________________________
Payment history:

prompt

Is there an amount past due?

1 – 30 days slow
yes

31 – 60 days slow

more than 60 days slow

no

If yes, enter amount due and due dates. _______________________________________________________________
Provide reasons for past dues: ______________________________________________________________________
If past dues were due to foreign exchange problems, does applicant have evidence of local currency deposits on all payments
due?
yes
no
b) Provide the applicable supporting financial information on the PSOR. Check the box that applies to your transaction and
provide the information noted below the box
The transaction is for an amount up to $50,000:
•

credit agency report or trade reference or applicant’s ledger experience

The transaction is between $50, 001 and $100, 000:
•

credit agency report and trade reference or applicant’s ledger experience

The transaction is between $100,001 and $300, 000:
•

credit agency report,

•

two trade references or one trade reference and applicant’s ledger experience, or

•

two most recent years signed fiscal year-end statements

The transaction is between $300, 001 and $ 1,000,000:

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credit agency report

•

two trade references

•

audited or signed, unaudited financial statements for the last two fiscal years that adequately disclose financial
condition and afford a reasonable basis for reliance on the information provided.

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The transaction is between $1,000,001 - $10,000,000

2.

•

credit agency report

•

two trade references

•

bank reference

•

audited or signed unaudited financial statements for the last three fiscal years that adequately disclose financial
condition and afford a reasonable basis for reliance on the information provided.

The PSOR is the financial institution guarantor.
a. Provide details of the exporter’s experience with the financial institution guarantor. Include dates and amounts of previous
None
transactions with the PSOR or indicate
_________________________________________________________________________________________
b. Provide supporting financial information.

Check the box that applies to your transaction and provide the information noted below the box
The transaction is for an amount up to $1 million:
•

One favorable reference from creditor bank.

•

One short-term debt rating of the PSOR from S & P, Moody’s or Fitch IBCA. Ratings must be B, P-3 or F3 or better,
respectively.

OR
• Most recently published fiscal year end or interim statements or statement spreads from Fitch IBCA, or Bankscope.
The transaction is for between $1,000,001 and $10,000,000
•

One favorable reference from a creditor bank

•

If the PSOR does not have an acceptable current market rating, provide most recently published audited financial statements
that adequately disclose financial condition and were prepared in accordance with to accounting principles that afford a
reasonable basis for reliance on the information provided.

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Attachment II
Pre-shipment Questionnaire
Details of Coverage Requested
a) Provide the reason pre-shipment coverage is requested _____________________________________________________________
b) Indicate the date the contract was executed or the anticipated date of signing
c) Indicate the estimated period between the contract date and the final shipment date
d) Provide a schedule of any progress payments made or to be made by the buyer or during the pre-shipment period, or indicate none:
___________________________________________________________________________________________________________

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APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE
Attachment III. Enhanced Assignment Questionnaire
If requesting Enhanced Assignment, attach
•

A bank reference on the exporter/applicant dated within six months of the application

•

Two trade references dated within six months of the application

•

Financial statements on the exporter/applicant as follows, for a policy limit of liability of:
$500,000 or less signed by an authorized officer for the applicant/exporter
$500,001 - $999,999 reviewed by a CPA with notes attached
$1,000,000 or more audited by a CPA with opinion and notes attached

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OMB #3048-0018
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APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE

Attachment IV Additional Named Insured Questionnaire
Indicate the name of the additional named insured as follows:

Legal Name: ________________________________________________________________________________________________
Address: ___________________________________________________________________________________________________
City: ______________________________________________________________________________________________________
State: ______________________________________________________________________________________________________
Country: ____________________________________________________________________________________________________
Zip/ Postal Code: _____________________________________________________________________________________________
Relationship to Applicant: _____________________________________________________________________________________
Role in the transaction: ________________________________________________________________________________________
E-mail: ____________________________________________________________________________________________________
Contact person: ______________________________________________________________________________________________

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APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE
Attachment V – Warehouse Information
If you requested the Special Coverage – Warehouse, answer the following questions about the warehouse

Warehouse Type:

Owned or controlled by exporter
Bonded warehouse
Neither

Warehouse Location:

City ______________________________________________________________________________

State/Province ______________________________________________________________________

Country____________________________________________________________________________

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