Form EIB 10-02 EIB 10-02 Application for Express Insurance

Print Form

EXPORT-IMPORT BANK
of the UNITED STATES

OMB No. 3048-xxxx

APPLICATION FOR EXPRESS INSURANCE
dba

Applicant

Website:

Address:
Email:

Fax:

Phone:

Email:

Title:

Contact:

Broker Contact:

Brokerage:

Is the majority ownership of your business represented by:
women or
How did you learn about Ex-Im Bank?
Broker
Ex-Im Bank Regional Office
Ex-Im Bank City/State Partner

Other

1. Primary reason for application:

a minority?
Bank

U.S. Export Assistance Center

(describe):

risk mitigation

extend more competitive terms

financing

2. Do you have a credit line with a financial institution (exclude overdraft protection and credit cards)
3. Do you have an SBA or Ex-Im Bank Working Capital Loan? SBA

NO

YES

EXIM

YES

NO

YES

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 three years for you and your affiliates: $
6. Do you wish to insure export credit sales made by your affiliates? (If yes, please attach names/addresses of each)

YES

NO

7. Product and/or services to be exported & NAICS (if known):
8. Do you sell Capital Goods to foreign manufacturers or producers?

YES

NO (if yes, attach explanation)

9. Are the Products to be covered under the policy:
Manufactured or reconditioned in the U.S.?

YES

NO

All made or reconditioned with more than 50% U.S. content?

YES

NO

Shipped from the U.S.?

YES

NO

Used to support Nuclear Energy?

YES

NO

Sold to Military entities or Security Forces?

YES

NO

On the U.S. Munitions List?

YES

NO

Environmentally Beneficial?

YES

NO

Supporting Renewable Energy?

YES

NO

10. Policy Payment Limit Requested: $
11. Year you began: a) Exporting?

(If no, attach explanation)

(part 121 of title 22 of the Code of Federal Regulations)

(maximum export credit receivables outstanding at any one time)
b) Exporting on credit terms (other than cash in advance or confirmed letters of credit)?

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

13. Total export credit receivables outstanding $

Losses

of which $

is more than 60 days past due at

(date must be within 30 days of application date)
14. Your most recent FYE date
NET Sales

EIB10-02
Created: 05/10

15. Requested credit amount

& terms:

days

required for a buyer you wish to insure. Provide full Buyer Name/Address:

NET Profit or (Loss)

Name

Total Assets

Address

Equity

City

State

Zip Code

Country

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CERTIFICATIONS AND NOTICES

OMB No. 3048-xxxx

The Applicant (hereafter “Applicant” or “it”) CERTIFIES, ACKNOWLEDGES and COVENANTS to the Export-Import Bank of the United
States (hereafter “Ex-Im Bank”) that to the best of Applicant's knowledge and belief, after due diligence, the statements set forth below are true
and correct. Any reference below to “this transaction” shall refer to either the individual transaction or the Ex-Im Bank program or Insurance
Policy that is the subject of the application, as appropriate.

A.

B.

C.

D.

E.
F.

Neither Applicant, nor any of its Principals (as defined in the Debarment Regulations identified below), has, within the past 3 years, been:
1) debarred, suspended, declared ineligible from participating in, or voluntarily excluded from participation in a Covered Transaction (as defined in the ExIm Bank and Government-wide debarment regulations, found at 2 CFR Part 3513 and 2 CFR Part 180, respectively) (collectively the “Debarment
Regulations”);
2) formally proposed for debarment from participating in a Covered Transaction, with a final determination still pending;
3) indicted, convicted or had a civil judgment rendered against it for any conduct or offenses described at 2 CFR § 180.800 in the Debarment Regulations;
4) delinquent on any amounts due and owing to the U.S. Government or its agencies or instrumentalities as of the date of execution of this certification; or
5) listed on any of the publically available debarment lists of the following international financial institutions: the World Bank Group; the African
Development Bank; the Asian Development Bank; the European Bank for Reconstruction and Development, and the Inter-American Development Bank;
or
the Applicant has received a written statement of exception from Ex-Im Bank attached to this certification, permitting acceptance of this application
notwithstanding an inability to make all of the certifications in clauses1) through 5) of this section A.
Applicant has conducted and will conduct reasonable due diligence in connection with this transaction, including checking the Excluded Parties List
System (http://www.epls.gov/epls/search.do) (“EPLS”) and the Specially Designated Nationals (“SDN”) List of the Department of the Treasury,
Office of Foreign Assets Control (“OFAC”) (http://www.ustreas.gov/offices/enforcement/ofac/sdn/). Applicant will not knowingly enter into any sales,
leasing or financing agreements in connection with this transaction with any individual or entity that is listed on the EPLS or the SDN List (or is otherwise
prohibited from conducting business with U.S. public and private entities pursuant to OFAC Regulations).
Either: (1)To the best of Applicant's knowledge and belief, no funds have been paid or will be paid to any person in connection with this application for
influencing or attempting to influence:
(a) an officer or employee of any U.S. Government agency, or
(b) a Member of Congress or a Member's employee, or
(c) an officer or employee of Congress;
(This does not apply to commissions paid by the Bank to insurance brokers.)
or (2) Applicant will complete and submit Form-LLL (the Anti-Lobbying Declaration/Disclosure forms available at http://www.exim.gov/tools/appsforms/
documents/eib95-10all.pdf)
Neither Applicant nor any agent or representative acting on Applicant's behalf, has or will engage in any activity in connection with this transaction that is a
violation of: 1) the Foreign Corrupt Practices Act of 1977, 15 U.S.C. § 78dd-1, et seq.; 2) the Arms Export Control Act, 22 U.S.C.§ 2751 et seq., 3) the
International Emergency Economic Powers Act, 50 U.S.C. § 1701 et seq., 4) the Export Administration Act of 1979,50 U.S.C. § 2401 et seq., and,
5) the regulations issued by the OFAC. Applicant also certifies that neither Applicant nor any agent or representative acting on Applicant's behalf, has
been found by a court of the United States to be in violation of any of the foregoing statutes or regulations 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 of the foregoing or any other
applicable law.
Neither the Applicant nor any agent or representative acting on Applicant's behalf in connection with this transaction is currently under charge or has
been, within the past 5 years, convicted in any court of any country, or subject to national administrative measures of any country, for bribery of public
officials.
The representations made and the facts stated in this application and its attachments are true and Applicant has not misrepresented or omitted any
material facts. Applicant further covenants that if any statement(s) set forth in this application becomes untrue, or is discovered to have been untrue when
made, Applicant will promptly inform Ex-Im Bank of such change. Applicant further understands that in accepting or approving this application, Ex-Im Bank
is relying upon Applicant's statements set forth in the application and on the foregoing certifications, and all statements and certifications to Ex-Im Bank are
subject to the penalties for false or misleading statements to the U.S. Government (18 USC § 1001, et. seq.).

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. If any of the information provided in this application changes in any material way or if any of the certifications made herein become untrue,
the applicant must promptly inform Ex-Im Bank of such changes. 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). Ex-Im Bank reserves the right
to decline to process or to discontinue processing of an application.

Paperwork Reduction Act Statement: We estimate that it will take you about 1 hour per response that includes the time it will take to read the instructions,
gather the necessary facts and fill out the form. However, you are not required to provide information requested unless a valid OMB control number is displayed
on the form. If you have comments or suggestions regarding the above estimate or ways to simplify this form, forward correspondence to Ex-Im Bank and the
Office of Management and Budget, Paperwork Reduction Project, OMB # ????????? Washington, D.C. 20503.

EIB10-02
Created: 05/10

(Signature)

(Print Name and Title)

(Date)
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