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

OMB
PENDING-2014

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
 Ex-­‐Im

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:

  _________________

Phone:
 (_____)
  _______________
  Fax:
 (_____)

  _________________

 Email:

 _____________________________________

Tax
 ID#:

 __________________________

 DUNS
 #:
  _________________________

 No.
 of
 Employees:

  __________________

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)
2)
3)
4)
5)

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

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

Attach
 evidence
 of
 current
 professional
 liability
 insurance
 coverage.

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

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
 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).

EIB-­‐92-­‐79
 (03/14)

 Page
 1
 of
 5

OMB
PENDING-2014

2.

3.

4.

5.

6.

7.

8.

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.

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.

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).

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.

Public
 Burden
 Statement.

 We
 estimate
 that
 it
 will
 take
 you
 about
 2
 hours
 per
 response
 including
 reviewing

instructions,
  searching
 data
 sources,
 gathering
 information,
 completing,
 and
 reviewing
 the
 application.

 However,
 you

are
 not
 required
  to
 provide
 information
 requested
 unless
 a
 valid
 OMB
 control
 number
 is
 displayed
 on
 the
 form.

Please
 send
 comments
  regarding
 the
 burden
 estimate,
 including
 suggestions
 for
 reducing
 it
 to:
 Export
 Import

Bank,
 Broker
 Relations,
 811
  Vermont
 Ave.,
 N.
 W.
 Washington,
 D.C.
 20571
 and
 Office
 of
 Management
 and
 Budget,

Paperwork
 Reduction
 Project,
  OMB
 #
 3048-­‐0024,
 725
 17th
 Street,
 N.W.,
 Washington,
 D.C.
 20503.

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.

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:

 _________________________________________

 Print
 Name:

  _______________________________________

Title:

  _____________________________________________

 Date:

 _____________________________________________

Send
 this
 application
 to
 Attn:
 Broker
 Relations,
 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

EIB-­‐92-­‐79
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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:

  ____________________________

Print
 Name:

 ___________________________________
 Date:

  ________________________________________

EIB-­‐92-­‐79
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OMB
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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

  ________________________

 Zip

  ___________________________

TRANSIT/ABA
 NUMBER:
__
__
__
__
-
__
__
__
__
-
__

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

  ______________________________________________________________________________

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

EIB-­‐92-­‐79
 (03/14)

 Page
 4
 of
 5

OMB
PENDING-2014

Export-Import Bank of the United States
BROKER COMMISSION SCHEDULE
FOR EXPORT CREDIT INSURANCE POLICIES

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
 $7.5
 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
 Mr.
 Thomas
 Cummings,
 Director,
 Broker
 Relations
 at
 212-­‐809-­‐2652
 or

[email protected],
 290
 Broadway
 Floor
 13,
 New
 York,
 NY
 10007

 Or:
 an
 Ex-­‐Im
 Bank
 Regional
 Office:
 EASTERN
 REGION:

Miami
 305.526.7436,
 Atlanta
 404.815.1497,
 New
 York
 212.809.2650;
 CENTRAL
 REGION:
 Chicago
 312.353.8081,
 Detroit

313.309.4158,
 Minneapolis
 612.348.1213,
 Dallas
 214.551.4959,
 Houston
 281.721.0465;
 WESTERN
 REGION:
 Irvine
 949.660.1341,

San
 Diego
 858.467.7035,
 San
 Francisco
 415.705.2285,
 Seattle
 206.728.2264

General
 Inquiries:
 TEL.
 202.565.EXIM
 (3946)
 OR
 1.800.565.EXIM
 (3946);
 FAX
 202.565.3723;
 www.exim.gov;
 [email protected]

EIB-­‐92-­‐79
 (03/14)

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