Form EIB 92-50 OMB 3048 EIB 92-50 OMB 3048 Short-Term Multi-biyer Export Credit Insurance Policy Ap

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OMB No. 3048-00 23
Expires 08/31/2010

EXPORT IMPORT BANK OF THE UNITED STATES
SHORT-TERM MULTI-BUYER EXPORT CREDIT INSURANCE POLICY APPLICATION
Applicant:
Address:

dba:

Phone:
Fax:
Contact:
Title:
Brokerage:_____________________________

E-Mail:
Website:
E-Mail: ______________ Phone: ______________
Broker Contact:_____________________________________

(optional) Is the majority ownership of your business represented by ___ women or ___ an ethnic minority?
How did you learn about Ex-Im Bank? ___ Ex-Im Bank Regional Office ___Broker ___Bank ___ U.S. Export Assistance Center
___ Ex-Im Bank City/State Partner ___ Other (describe):__________________________________________________________
1. Primary reason for application:

risk mitigation

financing

extend more competitive terms

2. Do you have a credit line with a financial institution (exclude overdraft protection and credit cards)
SBA
EXIM

3. Do you have an SBA or Ex-Im Bank Working Capital Loan or are you applying for one?

YES

NO

YES
YES

NO
NO

4. Total number of your employees and those at companies with whom you are affiliated: ______
5. Average total of annual export credit sales over the last two years for you and your affiliates:$_____________
6. Do you wish to insure export credit sales made by your affiliates? (If yes, please refer to “additional named insured” eligibility
criteria in question # 24. Answers to all remaining questions must include eligible affiliates you wish to add.)
7. Product and/or services to be exported & NAICS (if known):
YES

8. Do you sell Capital Goods to foreign manufacturers or producers?

NO

(if yes, attach explanation)

9. Are the products to be covered under the policy:
•
•
•
•
•
•
•
•

Manufactured or reconditioned in the U.S.?
Made or reconditioned with more than 50% U.S. content?
Shipped from the U.S.?
Sold to Military entities or Security Forces?
Used to support Nuclear Energy?
Environmentally Beneficial?
Supporting Renewable Energy?
On the U.S. Munitions List?
(part 121 of title 22 of the Code of Federal Regulations)

Yes
Yes
Yes
No
No
Yes
Yes

No
No
No
Yes
Yes
No
No

No

Yes

Note: Your buyers, their guarantors (if any), and end users of the products must be in countries where Ex-Im Bank is able to provide
support, see Ex-Im’s Country Limitation Schedule (CLS) at www.exim.gov . There may not be trade measures or sanctions against
them under Section 201 Trade Act of 1974 . For a list of products and countries with Anti-Dumping or Countervailing Duty sanctions,
see Anti-Dumping or Countervailing Sanctions).
10. Policy Payment Limit Requested: $__________________ (maximum export credit receivables outstanding at any one time)
11. Buyer Types: ____% Manufacturers ____% Wholesalers/Traders ____% Retailers ____%Service Providers
12. Projected # of buyers to whom you will offer export credit terms:______
13. Enter the percentage of export credit sales by payment and term type projected for the next twelve months:

EIB92-50
1/07

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Payment Type

Unconfirmed L/C
Open account or Draft

Sight

1-30

___%
___%

___%
___%

OMB No. 3048-00 23
Expires 08/31/2010

Terms (# of days)
(must total 100%, collectively)
31-60
61-90
91-120
121-180
___%
___%

___%
___%

___%
___%

___%
___%

181-270

271-360

___%
___%

___%
___%

(enter “Cash Against Documents” in the “Sight” column and “Open account/Draft” row)
14. Export Credit Portfolio (enter amounts for the next 12 months. If more than 9 countries, enter the balance in “all other”).
Country Exp
$
$
$
$

ort Credit Sales

$

Country Exp
$
$
$
$
“all other countries”

ort Credit Sales

$

15. Identify your three largest buyers:
Name
__________________________________
__________________________________
__________________________________
16. Year you began:

Country
________________________
________________________
________________________

Export Credit Sales (next 12 months)
$______________________
$______________________
$______________________

a) exporting? ______
b) exporting on credit terms (other than cash in advance or confirmed letters of credit)?_____

17. For the last three years what were your total export credit:
(include factored or insured receivables and attach any comments)

sales
write-offs
# of accounts written-off

$
$

18. Highest average amount of export receivables outstanding over the last twelve months: $______________
19. Total export receivables outstanding: $__________________ at ___/___/___ (date should be within 30 days of the application)
$_____________
current

$_____________
1-60 days past due

$_____________
61-90 days past due

$______________
91-180 days past due

$______________
> 180 days past due

20. Number of buyers past due more than 60 days for $10,000 or more:
21. For each buyer over 60 days past due for $10,000 or more, attach an explanation including name of buyer, country, amount past
due, due date, and reason for past due.
Years of
Years of
22. Name(s) of export credit decision maker(s): Title(s):
Credit Experience
Foreign Credit Exp.

23. Please submit the following as Attachments:
• Credit Report on your company dated within 6 months of the application or attach a check for $35 payable to Ex-Im Bank.
• Your financial statements for the two most recent completed fiscal years (with notes if available)
• Descriptive product brochures (if available).
• Other pertinent information you wish to include.

EIB92-50
Revised 1/2007

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24. Special Coverages Required: If “none” check

OMB No. 3048-0023
Expires 08/31/2010

N/A

Add Additional Named Insureds (ANI’s). Credit decisions of each affiliate listed must be centralized with the Applicant
and each affiliate must invoice export credit sales in their own name (or tradestyle); if either is not applicable, please attach an
explanation. Questions 7-25 should include export sales of prospective ANI’s.
Are the products of each affiliate the same as the applicant’s products listed in question 4 of this application?
Affiliate Company/Trade style

Street Address/City / State / Country

NAICS Code

Yes

No

Relationship to Applicant

Services (Please attach a copy of your sample services contract) Services must be: performed by U.S. based personnel or
those temporarily domiciled overseas, and billed (invoiced) separately from any product sales.
Enhanced Assignment of small business insurance policy proceeds. This is exporter performance risk protection that may be
offered to lenders willing to finance Ex-Im Bank insured receivables. Applicant Please Attach:
• Written bank reference describing your relationship to date and size of existing credit line.
• 2 written trade references from principal commercial suppliers.
• For applications with policy limits over $500,000, financial statements must be audited or CPA reviewed with notes.
Other (please specify):
25. Please complete the Exclusion Worksheet on page 5 to request coverage exclusion of any export credit sales.
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 th at it has not and will not knowingly enter into any agreements, in con nection with the products and
services to be exported in the transaction described herein, with any individual or en tity that has been debarred, suspended, declared
ineligible from participating in, or voluntarily excluded from participation in a Covered Transaction. The term "Covered Transaction"
shall have the meaning set forth in the Ex-Im Bank Debarment Regulations. "Debarment Regulations" shall mean, collectively:
(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. The applicant is not listed on any
of the publicly available debarment lists of the following international financial institutions: World Bank Group, African Development
Bank, Asian Development Bank, European Bank for Reconstruction and Development and the Inter-American Development Bank.
In addition, the applicant certifies that neither the applicant nor anyone acting on its behalf, such as agents, has engaged, or will
engage, in any activity in connection with this transaction that is a violation of the Foreign Corrupt Practices Act of 1977, 15 U.S.C.
78dd-1 et seq. (which provides for civil and criminal penalties against companies and individuals who directly or indirectly make or
facilitate corrupt payments to foreign officials to obtain or keep business). Further, the applicant has not engaged, and will not engage,
in any activity in connection with this transaction that is a violation of the Arms Export Control Act, 22 U.S.C. 2751 et seq., the
International Emergency Economic Powers Act, 50 U.S.C. 1701 et seq., or the Export Administration Act of 1979, 50 U.S.C. 2401 et
seq. The applicant has not 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 neither the applicant nor anyone acting on its behalf in connection with this transaction is currently under
charge or has been, within the past 5 years, convicted in any court or subject to national administrative measures of any country for
bribery of foreign public officials.
Further, 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 U.S.C. 1001 et seq.).
(Signature)
EIB92-50
Revised 1/2007

(Print Name and Title)

(Date)

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SMALL BUSINESS POLICIES APPLICANT CERTIFICATION

OMB No. 3048-0023
Expires 08/31/2010

"We are an entity which together with our affiliates had average annual export credit sales during our preceding two fiscal years
not exceeding $5,000,000, excluding sales made on terms of confirmed irrevocable letters of credit (CILC) or cash in advance (CIA).”

NOTICES
The applicant is hereby notified that information requested by this application is done so under authority of t he Export-Import Bank
Act o f 1945, a s am ended (12 U. S.C. 635 et seq. ); provision o f t his i nformation i s m andatory a nd fa ilure t o provide t he re quested
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 inform ation and ap plicants are not required t o provide in formation requested in th is ap plication un less a cu rrently v alid OMB
control number is displayed on this form (see upper right of each page).
Public Burden Stateme nt: Rep orting fo r th is co llection of in formation is esti mated to av erage 1 ho ur p er resp onse, in cluding
reviewing i nstructions, searc hing data so urces, gat hering i nformation, completing, an d re viewing t he ap plication. Send c omments
regarding t he burden est imate, i ncluding s uggestions for re ducing i t, t o Office o f M anagement an d B udget, Paperwork R eduction
Project OMB# 3048-0009, Washington, D.C. 20503.
Send, or ask your insurance broker or city/state participant to review and send this application to the Ex-Im Bank Regional
Office nearest you. Please refer to Ex-Im Bank’s website at http://www.exim.gov for Regional Office addresses. Alternatively,
email your application and attachments to Ex-Im Bank at [email protected], or fax it to (202) 565-3675.
Ex-Im Bank reserves the right to request additional information upon review of the application. Please refer to Ex-Im Bank’s
Short Term Credit Standards (EIB 99-09) to determine the likelihood of approval of a policy.

EIB92-50
Revised 1/2007

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