OPIC-Form 50 - Request for Registration1

		OPIC-50 OMB No. 3420-0001
Request for Registration For Political Risk Insurance Overseas Private Investment Corporation An Agency of the United States Government 1100 New York Avenue, N.W. Washington, DC 20527 www.opic.gov Insurance Department Tel.: (202) 336-8400 Fax: (202) 408-5142
	INSTRUCTIONS:
	Thank you for informing us of your interest in OPIC programs. This form is to be used in registering proposed investment projects for OPIC political risk investment insurance. To ensure that the project remains eligible for OPIC insurance, you should submit this form to OPIC prior to making an irrevocable investment commitment. Registration letters will not be issued for investments irrevocably committed, prior to the date of your request. This form may be downloaded from OPIC’s web site at http://www.opic.gov/insurance/apply/index.asp.
	There is no fee for registering a project for OPIC insurance. Upon acceptance of this request, you will receive a letter from OPIC acknowledging that your project has been registered. The letter does not commit OPIC to providing political risk insurance, nor does registration commit the applicant to purchasing OPIC insurance. For insurance to be issued, the investor must submit a formal application for insurance (wherein the information submitted in this registration form may be amended) and the investment must meet all statutory and policy requirements. For your convenience, OPIC can provide you with the application in printed form as well as on disk. The application form may also be downloaded from OPIC’s website at http://www.opic.gov/insurance/apply/index.asp.
	Please type or print clearly and sign this form prior to submission. If you have questions or require further assistance, please do not hesitate to contact OPIC’s Insurance Applications Officer at (202) 336-8595.

Part 1: Investor Information

1.

Investor:

Contact:

                         

Title:

                    

Address:

                                             

City:

               

State:

     

Zip/Postal Code:

          

Country:

               

Telephone:

               

Fax:

               

E-Mail:

               

Web site:

               

Parent Company Name (if applicable):

     

Applicant’s (or parent company’s) most recent consolidated annual sales (or stockholder’s equity for non-industrial companies):

$      

2.

Investor is:



A U.S. Citizen



An entity more than 50% beneficially owned by U.S. citizens



A foreign corporation more than 95% owned by one of more such U.S. entities or U.S citizens



A foreign entity (other than a corporation) 100% owned by one or more such U.S. entities or U.S. citizens

3.

How did you hear about OPIC?



Conference



OPIC Web site



Other Govt. Agency (SBA, TDA, EX-IM etc)



Insurance Broker



Former OPIC clients



Other (please specify)

          

Part 2: Project Information

4.

Where will the project be located?

City:

Country:

5.

Please describe the project

(a)

What products/services will be rendered?

     

(b)

Will you have a contract with the host government to provide these products or services?



Yes



No

(c)

The enterprise you will be investing in is:



New



An existing business to be expanded or improved.

(d)

Does the host government have any investment in the enterprise?



Yes



No

If Yes, the host government owns:

      %

(e)

Could this project result in reduced U.S. employment?



Yes



No

(f)

Could this project result in significant adverse environmental impacts?



Yes



No

Part 3: Investment to be Made

6.

Investment to be Made

(a)

Total amount of investment :

$      

(b)

Estimated date of investment:

(c)

Has any portion of this investment been made or irrevocably committed as of the date of registration?



Yes



No

If yes, please explain and indicate when the investment was made.           

(d)

What do you plan to insure?

Investors

Contractors & Exporters



Equity



Loan Guaranty



Bid Bond



Contract Disputes



Debt



Technical Assistance



Assets



Performance/Advance Payment Guaranties



Lease



Other:

     



Other:

     

Part 4: Insurance Broker or Agent

7.

This registration is being submitted:



By the Investor

OR



By a U.S. licensed broker or brokerage agency

OR



By an agent*

Contact:

                         

Title:

                    

Address:

                                             

City:

               

State:

     

Zip/Postal Code:

          

Country:

               

Telephone:

               

Fax:

               

E-Mail:

               

*An agent assists the insured without engaging in activities (including, inter alia, the solicitation, negotiation or placement of insurance) for which a license is required pursuant to applicable State or Federal insurance regulation.

8.

Who will complete the OPIC insurance application (Form 52)?



Investor



U.S. licensed broker or brokerage agency



Agent

Part 5: Signature

Investor Signature:

     

Date:

FOR OPIC USE ONLY
	Route To:	     		Approved					Rejected
	Registration No.:	     	Signature:						Date:	     
	Registration Date:	     		Special Letter		(specify:)
	Project Description:	     		Issue Letter of Intent
	SIC CODE: