Form EIB 92-79 EIB 92-79 Broker Registration Form

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0MB #3048-0024
Expiry Date 08/31/2010

EXPORT-IMPORT BANK OF THE UNITED STATES (EX-IM BANK)
COMMISSIONED BROKER APPLICATION FORM
Subject to compliance with the terms and conditions of this Application and the attached Standards of Professional Conduct
and Service, an insurance broker may become registered with Ex-Im Bank and eligible for commission payments under ExIm Bank export credit insurance policies if the broker is appointed as broker-of-record by the policyholder either by
designation on an insurance policy application or by separate letter. The commission payments shall be based on Ex-Im
Bank’s “Broker Commission Schedule” in effect at the time of shipment in the brokered transaction.
Name of Brokerage___________________________________________________
Contact: ____________________ __________________Title:________________________________
Address: _____________
PO Box: _________________
City: _____________________State: _______________Zip:___________________________
)
Fax: (
)
E-Mail:_______________
Phone: (
Tax ID #: _____________________ DUNS #: ________________________ No. of Employees: _____
Indicate (Not Required) if owned by a woman or an ethnic minority, describe ___________________________
Other lines of brokered Insurance: _________________________________________________
Do you have other offices you wish to register (to be eligible for commissions)? _____No ____Yes
If “Yes”, please list firm’s name, address, telephone number, fax number and contact person on a separate sheet. A list of
registered insurance brokers is available on Ex-Im Bank’s website and unbrokered applicants are referred to the list.
Please indicate here if you DO NOT wish to have your name released.
APPLICATION REQUIREMENTS AND INSTRUCTIONS
1.

Sign and return the attached “Standards of Professional Conduct and Service”.

2.

Attach a copy of a current, valid State insurance brokerage license indicating issuance and/or expiry date(s).

3.

Attach evidence of current professional liability insurance coverage.

4.

Sign and return the attached “Authorization for Automated Deposits” form.

5.

Submit a description of your business operations, which should include at a minimum: (i) relevant background and
history of your company; (ii) description of your expertise in export credit insurance products; (iii) your plan to
promote Ex-Im Bank programs to U.S. exporters; and (iv) a list of the names of all individuals licensed to broker
insurance and the States in which they are licensed.
CERTIFICATIONS AND NOTICES

The Broker (it) CERTIFIES and/or ACKNOWLEDGES to Ex-Im Bank the following:
1.

Debarment, Suspension and Delinquency. (a) Neither it nor its principals has been within the past 3 years (i)
debarred, suspended or declared ineligible from participating in or voluntarily excluded from participation in a
“Covered Transaction” defined in the Government wide Debarment and Suspension (Nonprocurement) regulations
and the Export-Import Bank of the United States Debarment and Suspension (Nonprocurement) regulations.; (ii)
formally proposed for debarment, with a final determination still pending; (iii) or indicted, convicted or had a civil
judgment rendered against it for any of the offenses listed in the Government wide Debarment and Suspension
(Nonprocurement) regulations; and
(b) Neither it nor its principals is delinquent on any amounts due and owing to the U.S. Government, its
agencies or instrumentalities as of the date of this application; and
(c) In connection with a transaction, it has not and will not knowingly enter into any agreements or affiliations
with any individual or entity to whom items (a) or (b) above apply; or
(d) It has received a written statement of exception from Ex-Im Bank and attached it to this certification,
permitting participation in the transaction despite an inability to make certifications (a)(i)-(iii), (b) and (c).

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Lobbying. It will complete and submit SF Form-LLL, Disclosure Form to Report Lobbying if, to the best of its
knowledge and belief, any funds have been paid or will be paid to any person for influencing or attempting to
influence, in connection with this application: (a) any officer or employee of any U.S. Government agency; or (b)
any Member of Congress or a Member’s employee; or (c) any officer or employee of Congress.

3.

Corrupt Practices. Corrupt payments made in connection with Bank supported transactions may be a violation of
the Foreign Corrupt Practices Act of 1977 (15 USC 78dd-l, et. seq.) or other applicable law or regulation 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.

4.

Notice of Authority to Request Information. The broker is hereby notified that the information being requested is
done so under authority of the Export-Import Bank Act of 1945 (12 USC 635 et seq.) and other applicable laws and
regulations. Provision of this information is mandatory and failure to provide the requested information may result
in Ex-Im Bank being unable to determine eligibility to be a registered broker for Ex-Im Bank’s Insurance Program.
The information provided will be reviewed to determine if the broker meets Ex-Bank’s requirements under the
program. Ex-Im Bank may not require the information requested, and applicants are not required to respond, unless
a currently valid OMB control number is displayed on this form (see upper right of each page).

5.

Confidentiality and Disclosure Notice. The information provided will be held confidential subject to the
requirements of the Freedom of Information Act (5 USC 552 et seq.), the Privacy Act of 1974 (5 USC 552a et seq.),
and other applicable laws. Ex-Im Bank shall have a right to transfer to another U.S. Government authority any
financial records included in this certification or other correspondence as necessary to process, service, foreclose or
collect on an insured debt or for any other lawful purpose.

6.

Public Burden Statement. The public burden reporting for this collection of information is estimated to average 2
hours 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, Washington, D.C. 20503.

7.

Standards of Professional Conduct and Service. The broker must sign the Standards of Professional Conduct and
Service in connection with this Application and every three years thereafter. Ex-Im Bank reserves the right to
withdraw or rescind a broker’s registration with Ex-Im Bank: (i) immediately for cause; or (ii) at any time, without
cause, upon 30 days prior written notice. "Cause" includes the breach of any applicable Standard of Professional
Conduct and Service and may also include other conduct such as, in Ex-Im Bank's sole determination, an excessive
claims history associated with transactions brokered by such broker, or a reasonable belief that the broker was
involved in fraudulent or wrongful activity, or that the broker knew or should have known that a specific transaction
was tainted by fraud. Removal from the list of registered brokers will result in the cancellation of eligibility to
receive commission payments from Ex-Im Bank.

8.

False Claims. The representations made by the broker and the facts stated by it in these certifications and its
attachments are true, to the best of its knowledge and belief, and it has not misrepresented or omitted any material
facts. It further understands that these certifications are subject to the penalties for fraud against the U.S.
Government (18 USC 1001 et seq.).

Signature: _________________________

Title: _________________

Print Name: __________________________

Date: ______________________

Send this application to Attn: Business Development, Ex-Im Bank,
811 Vermont Avenue, NW, Washington, D.C. 20571 or an Ex-Im Regional Office.
The Ex-Im Bank website is http://www.exim.gov

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EX-IM BANK INSURANCE BROKERS
STANDARDS OF PROFESSIONAL CONDUCT AND SERVICE
At all times while registered as a broker with Ex-Im Bank, the broker (“you”) shall:
1.

Act in a professional, reasonable, prudent and forthright manner and at all times with the utmost good faith and
integrity, in all dealings with your client and Ex-Im Bank;

2.

Make certain that your clients and third parties understand that you are neither an employee of Ex-Im Bank nor
an official representative of Ex-Im Bank;

3.

Stay knowledgeable about not only Ex-Im Bank export credit insurance but also alternatives, including other
Ex-Im Bank programs, other U.S. government programs, and private sector products as well, in order to
provide the best options to your clients;

4.

Educate yourself, agents, employees and your clients about Ex-Im Bank’s insurance program and policies,
including their benefits and proper usage;

5.

Serve as your clients’ primary contact for any questions concerning Ex-Im Bank policies and procedures and
the servicing of an Ex-Im Bank insurance policy;

6.

Review all applications, issued policies, renewals of policies and credit limits, and claims, for timeliness,
completeness, accuracy and reasonableness;

7.

Review correspondence from Ex-Im Bank with your clients, including quotes and credit limits, to assist them in
understanding the coverage and their responsibilities;

8.

Seek from clients information about their circumstances and objectives as might reasonably be expected to be
relevant in enabling the broker to fulfill its responsibilities to them;

9.

Assist your clients to comply with the requirements of Ex-Im Bank insurance policies, including shipment
reports, premium payment and reports of overdue accounts, reporting policy cancellations, submission of
premium reconciliation reports, notifications of defaults and filing claims;

10.

Maintain knowledge of and comply with all applicable laws, rules, and regulations of any government agency,
or regulatory organization governing your professional, financial, or business activities;

11.

Promptly disclose to Ex-Im Bank, any termination of, or changes or suspensions related to, the insurance
brokerage license submitted in connection with this Application.

12.

Disclose to clients any material conflict of interest that could reasonable be expected to impair the broker’s
ability to make an unbiased and objective decision when making recommendations or taking actions;

13.

Organize and control the internal affairs of its insurance brokering business in a responsible manner, and where
staff are employed ensure that they are competent, suitable, and under adequate day-to-day supervision by a
registered insurance broker;

14.

Take reasonable steps to give customers sufficient information in a comprehensible and timely way to enable
them to make balanced and informed decisions about Ex-Im Bank’s export credit insurance policies; and

15.

Prior to authorization, disclose to Ex-Im Bank any fees or commissions received (or contemplated) related to,
or any other economic interest held in, the underlying transaction for which the broker is receiving Ex-Im Bank
commissions.

The undersigned hereby agrees to comply with the above Standards of Professional Conduct and Service and acknowledges
that the foregoing obligations are independent and separate from the obligations of the insured set forth in any Ex-Im Bank
export credit insurance policy.
_____________________
Name of Brokerage

________________________
Signature of Broker

________________
Date

_________________________
Print Name

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AUTHORIZATION FOR AUTOMATED DEPOSITS
(ACH CREDITS)

I hereby authorize the Export-Import Bank of the United States hereinafter called Ex-Im Bank, to initiate credit entries to my
[ ] CHECKING [ ] SAVINGS account (check one) indicated below and the depository named below, hereinafter
called DEPOSITORY, to credit the same to such account.
DEPOSITORY NAME______________________
BRANCH___________________________
CITY__________ STATE

TRANSIT/ABA NUMBER:

ZIP______________

____-____-_

ACCOUNT NUMBER: ______________________
This authority is to remain in full force and effect until Ex-Im Bank has received written notification from me of its
termination in such time and in such manner as to afford Ex-Im Bank a reasonable opportunity to act on it.
BROKER NAME_________________________________
(please print)
BROKER NO.___________________________
SIGNATURE

DATE______________

PLEASE ATTACH A VOIDED CHECK FOR THE ACCOUNT NAMED ABOVE
FOR EX-IM BANK USE ONLY
DATE RECEIVED
PROCESSED BY
Return to: Export-Import

Bank of the United States
Director Broker Relations
811 Vermont Avenue, N.W.
Washington, DC 20571
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EXPORT-IMPORT BANK OF THE UNITED STATES
BROKER COMMISSION SCHEDULE
FOR EXPORT CREDIT INSURANCE POLICIES
Effective: April 1, 2006
BROKER ELIGIBILITY
Insurance brokers and agents are eligible for commission payments under Ex-Im Bank export credit insurance policies if the
broker or agent is registered with Ex-Im Bank and is appointed as broker-of-record by the policyholder. The policyholder
reserves the right to appoint, delete or change the broker of record at any time. Brokers of record are entitled to any
commissions due on premiums paid prior to a change in the broker of record in accordance with the procedures set forth
below.
COMMISSION RATES
Commission rates paid by Ex-Im Bank are based on the type of policyholder to which the policy is issued, as shown in the
chart below:
Type of Policyholder Commission Rate (percentage of premium)
Financial Institutions 8%
Exporters
Multi-Buyer Policyholders: Ex-Im Bank Small Business* 40%
Multi-Buyer Policyholders: All others 15%
Short Term Single-Buyer Policyholders: SBA Small Business 15%
Short Term Single-Buyer Policyholders: All others 10%
Medium Term Single-Buyer: 10%
* Ex-Im Bank Small Business is defined as an exporter that meets applicable SBA small business criteria and that averages
annual export credit sales of $5 million or less over the past three years.
COMMISSION PAYMENTS
- The full amount of all premiums are due at the appropriate lockbox on or before the date specified in the policy.
- Insurance brokers should not remit premiums “net” of commission.
- Commission payments will be made monthly.
- No commission payments will be made on advance premium.
BROKER CHANGES ON EXISTING POLICIES
Ex-Im Bank policyholders may appoint or change their insurance broker at any time. Insurance brokers appointed after a
policy is issued will be recognized on the first day of the next month after the receipt of the policyholder’s written notice
appointing an insurance broker of record. Acknowledgment by Ex-Im Bank of a policyholder’s appointed insurance broker is
made by means of a policy endorsement. Insurance brokers acknowledged by Ex-Im Bank are eligible for commissions with
respect to transactions occurring after the effective date of the endorsement.
WHO TO CONTACT: For additional information, please contact Ms. Judith Rivera, Director, Broker Relations at 202565-3417 or [email protected], 811 Vermont Avenue, N.W., Washington, D.C. 20571 Or: an Ex-Im Bank Regional
Office: NORTHEAST 212.809.2650; MIDWEST 312.353.8081; SOUTHEAST 305.526.7436; SOUTHWEST
281.721.0465; WEST: Orange County 949.660.1341, San Diego 619.557.7091, San Francisco 415.705.2285
General Inquiries: TEL. 202.565.EXIM (3946) OR 1.800.565.EXIM (3946); FAX 202.565.3723; www.exim.gov;
[email protected]

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