Form EIB 10-02 EIB 10-02 Application for Short-Term Express Credit Insurance Poli

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EXPORT-IMPORT BANK
of the UNITED STATES

OMB No.: 3048-0031
Expires: 2/28/2014

APPLICATION FOR EXPRESS INSURANCE

Applicant:

dba

Street Address:
City:

Country:

State:

Phone:

Nine-digit zip code:
Email:

Fax:

Website:
Contact:

Email:

Title:

Brokerage:

Is the majority ownership represented by:
How did you learn about Ex-Im Bank?
Ex-Im Bank City/State Partner

1. Primary reason for application:

Other

women or

a minority?
Broker

Ex-Im Bank Regional Office
(describe):

risk mitigation

Bank

U.S. Export Assistance Center

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

YES

YES
EXIM

NO

NO

YES

NO

4. Average total of annual export credit sales over the last three years for you and your affiliates: $
5. Do you wish to insure export credit sales made by your affiliates? (If yes, please attach names/addresses of each)
Are the products of each affiliate the same as the applicant's?

YES

NO

If no, list them in question #6.

NO

Does each affiliate invoice export credit sales in its own name or trade style?
Are the credit decisions of each affiliate centralized with this applicant?

YES

YES

YES

NO

NO

If ‘No,’ provide comment:

6. Product and/or services to be exported & NAICS (if known):
7. Are the products:
Used
New
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

(If no, attach explanation)

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

10. For SBA defined Small Businesses Only:
A. Was each of the products to be covered under the policy manufactured or reconditioned with more than 50% U.S. content
(comprised of all direct and indirect costs including but not limited to labor, materials, research, and administrative costs, but
excluding net profit)?
YES
NO
B. If the answer to (a) is “No” because one or more of your products contains less than 50% U.S. content, then coverage is
available for the U.S. content only in each product with less than 50% U.S. content. Please indicate if you are seeking coverage for
products with less than 50% U.S. content.
YES
NO
C. If the answer to (a) is “No” you may also obtain coverage on an aggregated basis for all products on an invoice, provided that a
Content Report is submitted at the time of shipment (please see applicable Fact Sheets for information on aggregation). Please
indicate if you are seeking coverage on an aggregated basis. Please note that you may answer “Yes” to either or both (b) and
YES
NO
(c).
11. Policy Payment Limit Requested: $
(maximum export credit receivables outstanding at any one time)
12 Year you began: a) Exporting?

b) Exporting on credit terms (other than cash in advance or confirmed letters of credit)?

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

Losses

# of accounts written off

14. How many foreign buyers do you currently sell to on credit terms?
EIB10-02
Created: 02/11

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OMB No.: 3048-0031
Expires: 2/28/2014

15. Total export credit receivables outstanding $

of which $

is more than 60 days past due at

(date must be within 30 days of application date)
16. Your most recent FYE date

17. Requested credit amount

days

& terms:

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

NET Sales

Name

Operating Profit

Address

NET Profit or (Loss)

City

Total Assets

State

Zip Code

Country

Equity

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 http://www.exim.gov. There may not be trade measures or sanctions against the good
produced with the U.S. export under Section 201 of the Trade Act of 1974. For a list of products and countries with Anti-Duping or
Countervailing Duty sanctions, see section AD/CVD Orders available at http://www.usitc.gov/trade_remedy/731_ad_701_cvd/
investigations/active/index.htm. Trade sanctions are product and country specific (i.e., all firms within a country are subject to the order,
unless a specific firm is explicitly excluded).

Buyer Information
1. Do you have any ownership interest in or familial ties with the buyer?

2. Will the products be shipped directly to the buyer in the buyer’s country?

YES

YES

3. Is the buyer purchasing your product(s) for resale to another country/countries?

4. Any prior sales to the buyer?

YES

NO

If Yes, comment below

If No, comment below

NO

YES

NO

If Yes, comment below

NO

5. List the year of your first sale to the buyer.
6. Any prior sales to the buyer on credit terms? Exclude any Cash-in-Advance or Letter of Credit sales.

YES

NO

7. List the year of your first sale to the buyer on credit terms. Exclude any Cash-in-Advance or Letter of Credit sales.
8. Enter the total sales made to the buyer on credit terms over the last three years. Enter “0” if the buyer is new to you. $
9. Describe the payment terms extended to the buyer over the last twelve months:
Transaction Type

Maximum Tenor

10. What is the highest amount outstanding over the last twelve months for which you have been paid? $
11. Describe the buyer’s history over the last twelve months:
Prompt

1-30 days slow

31-60 days slow

61-90 days slow

90+ days slow

No experience

12. What is the amount now owed to you by the buyer? Enter “0” if none. $
13. What is the total amount now more than 60 days past due? Enter “0” if none. $
14. What is the reason for the buyer being past due to you?

15. Do you hold security on the amount past due?

EIB10-02
Created: 02/11

YES

NO

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CERTIFICATIONS AND NOTICES

OMB No.: 3048-0031
Expires: 2/28/2014

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.

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
Ex-Im 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 clauses 1) through 5) of this section A.

B.

Applicant has conducted and will conduct reasonable due diligence in connection with this transaction, including checking the System for Award
Management (https://www.sam.gov/portal/public/SAM/) (“SAM”) to determine if parties are excluded from U.S. Government transactions, 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 SAM or the SDN List (or is otherwise prohibited from conducting business with U.S. public
and private entities pursuant to OFAC Regulations).

C.

If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United
States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” (http://
www.exim.gov/pub/ins/pdf/lll.pdf) in accordance with its instructions.
Submission of this statement is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who
fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

D.

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.

E.

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.

F.

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 # 3048-0031 Washington, D.C. 20503.

(Signature)

EIB10-02
Created: 02/11

(Print Name and Title)

(Date)

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