Form OPIC-50 Request for Registration for Political Risk Investment I

CONFIDENTIAL COMMERCIAL INFORMATION

Part 1: Investor Information
1. Investor:
Contact:

Title:

Address
City:

State:

Country

Telephone:

E-Mail:

Web site:

Zip/Postal Code:
Fax

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?
OPIC sponsored workshop or
event

OPIC Web site or other
social media (Facebook,
Twitter)

Other US Government Agency (e.g.
State/Embassy, Commerce, Treasury,
TDA, SBA, USEXIM, etc.)

OPIC speaker at an industry
event

Insurance Broker

Current or 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)
(c)
(d)

OPIC-50

Will you have a contract with the host government to provide these products or services?
Yes
No
The enterprise you will be investing in is:
An existing business to be expanded or improved.
New
Does the host government have any investment in the enterprise?
Yes
No If Yes, the host government owns:
________%

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CONFIDENTIAL COMMERCIAL INFORMATION

(e)

Could this project result in reduced U.S. employment?
Yes
No
Could this project result in significant adverse environmental impacts?
Yes
No

(f)

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
Equity
Loan Guaranty
Debt
Technical Assistance
Lease
Other

Contractors & Exporters
Bid Bond
Contract Disputes
Assets
Performance/Advance Payment Guaranties
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:
Country:

State:
Telephone

Zip/Postal
Code:
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.

OPIC-50

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CONFIDENTIAL COMMERCIAL INFORMATION

8. Who will complete the OPIC insurance application (Form 52)?
Investor
U.S. licensed broker or brokerage agency
Agent

Part 5: Signature
Investor Signature:

OPIC-50

Date:

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