Form EIB 92-64 EIB 92-64 EIB 92-64, Application for Exporter Short Term Single Bu

OMB #3048-0018
10/31/2015

Export-Import Bank of the United States
APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE
This application is to be completed by an exporter (or a broker acting on its behalf) in order to obtain a short-term insurance policy
covering sales to a single foreign buyer. Repayment terms can be up to 360 days.
An online version of this application is available on Ex-Im Bank’s web site. Ex-Im Bank encourages customers to apply on line, as it
will facilitate our review and allow customers a faster response time. Additional information on how to apply for Ex-Im Bank
insurance can be found on Ex-Im’s web site http://www.exim.gov.
Send this completed application to Ex-Im Bank, 811 Vermont Ave., NW, Washington, D.C. 20571. Ex-Im Bank will also accept emailed pdf and faxed applications. Ex-Im Bank will not require the originals of these applications to be mailed. The application must
be PDF scans of original applications and all required attachments. (Fax number 202.565.3380, e-mail [email protected])

APPLICATION FORM
Items marked with an asterisk (*) are required fields. Under corporate ownership, provide name of ultimate parent company, if there is a
corporate owner. For number of employees and sales volume, aggregate for the company and all its affiliates2, including corporate
owners and subsidiaries.
*Applicant/Exporter Legal Name:
Tradestyle:
*Street Address:
*City:
*Corporate Ownership:
* Does the Applicant have any affiliates2:
Yes
*Total Number of Employees:
Contact Person:
Position Title:
*Minority-owned business:
Yes
*Woman-owned business:

Country:
*State:

*Zip + 4:
* Primary Industry NAICS1:

No
*Annual Sales Volume:
Email:
Phone:

Fax:

No

Decline to Answer

No

Decline to Answer

Yes

Decline to Answer
Yes
No
*Veteran-owned business:
company’s Primary Industry NAICS codes is the NAICS that accounts for the largest share of sales for the most recently completed fiscal year. The full definition of “primary industry” is set forth at 13
C.F.R. § 121.107.
2 Affiliations exist when one individual or entity controls or has the power to control another or when a third party or parties control or have the power to control both. Factors such as common
ownership, common management, previous relationships with or ties to another entity, and contractual relationships may cause affiliation. The complete definition of affiliation is found at 13 C.F.R. §
121.103.
1A

Broker (if applicable):
Name of Broker
Ex-Im Bank Broker#:
Contact Person:
Fax:
E-mail:
1. GENERAL QUESTIONS
A. Type of Coverage Requested
Comprehensive risk
Political risk
B. Qualification for Coverage
Will the applicant have title to the products at the time they are shipped?
Yes

No

Will the applicant directly invoice the buyer?
Yes

No

If you answered no to either, you may not be eligible for coverage. Call Ex-Im Bank or your broker for assistance.

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C. Primary Reason for applying for this policy
Risk mitigation
Financing
T o offer more competitive terms
D. Is this a resubmission of a previously withdrawn, returned or denied application, or a follow-on policy for the same buyer?
Yes
No
If yes, indicate previous transaction number:
E. Primary point of contact for this application
Exporter
B roker
2. SPECIAL COVERAGES
Check the boxes for the special coverage that apply to this transaction. Complete and attach the requested forms, where applicable.
Pre-shipment Cover Attachment II
Pre-shipment questionnaire required

Shipment to address in US

Bulk agriculture

Warehouse Attachment VWarehouse information required

Additional Named Insured
Attachment IV - ANI required

Enhanced assignment Attachment III
- EA questionnaire required

Services

Foreign currency coverage indicate
currency:
- currency of supply contract
US dollar
foreign currency

Other

3. PARTICIPANTS
Provide information on the additional participants to the transaction.
Supplier
The supplier is the U.S. entity that manufactures the goods and/or performs the services to be exported. Check
if the exporter is the
supplier and there are no additional suppliers. Enter any additional suppliers, or check
various:
Items marked with an asterisk (*) are required fields. Under corporate ownership, provide name of ultimate parent company, if there is a
corporate owner. For number of employees and sales volume, aggregate for the company and all its affiliates2, including corporate
owners and subsidiaries.
*Supplier Legal Name:
Tradestyle:
*Street Address:
*City:
*Corporate Ownership:
* Does the Supplier have any affiliates2:

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Country:
*State:
Yes

*Zip + 4:
* Primary Industry NAICS1:
No

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*Total Number of Employees:
Contact Person:
Position Title:
*Minority-owned business:

Yes

No

Decline to Answer

*Woman-owned business:

Yes

No

Decline to Answer

*Veteran-owned business:

Yes

No

Decline to Answer

*Annual Sales Volume:
Email:
Phone:

Fax:

1A

company’s Primary Industry NAICS codes is the NAICS that accounts for the largest share of sales for the most recently completed fiscal year. The full definition of “primary industry” is set forth at 13
C.F.R. § 121.107.
2 Affiliations exist when one individual or entity controls or has the power to control another or when a third party or parties control or have the power to control both. Factors such as common ownership,
common management, previous relationships with or ties to another entity, and contractual relationships may cause affiliation. The complete definition of affiliation is found at 13 C.F.R. § 121.103.

Buyer
The buyer is the entity that contracts with the exporter for the purchase of U.S. goods and services.
Buyer legal name:
State:
Contact person:
Country:
Position title:
E-mail:
Street Address:
Phone:
City:
Postal Code:
Fax:
Guarantor
The guarantor is the person or entity that agrees to repay the credit if the buyer does not. Refer to the Short-Term Credit
Standards to determine in what circumstances personal or corporate guarantors are required.
Is a guarantor involved in this transaction? Yes
No
If yes, is the guarantor
an individual or
a company?
Guarantor legal name:
Contact person:
Position title:
Street Address:
City:

Postal Code:

State:
Country:
E-mail:
Phone:
Fax:

End-user
The end-user is the foreign entity that uses the U.S. goods and services:
Check if the end-user is also the buyer .
End-User legal name:
Contact person:
Position title:
Street Address:
City:

Postal Code:

State:
Country:
E-mail:
Phone:
Fax:

Agent
An agent is a business entity or individual located in the country of the borrower or buyer who has assisted in the sourcing,
packaging, and/or preparation of a request for support from Ex-Im Bank, and which will receive compensation in some form for
their services.
Is an agent involved in the transaction? Yes

No

If yes, add the agent information below:
Agent legal name:
Contact person:
Position title:
Street Address:
City:

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Postal Code:

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State:
Country:
E-mail:
Phone:
Fax:

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Related Parties
Describe any direct or indirect ownership or family relationship that exists between any of the participants. If none, so indicate:
None.

Primary Source of Repayment
The PSOR is the entity whose financial statements or credit information form the basis of Ex-Im Bank’s evaluation of
reasonable assurance of repayment, i.e. the entity whose financial statements Ex-Im Bank uses to supply calculate the ratios
for Short-Term Credit Standards compliance. For this transaction, indicate whether the PSOR is:
the buyer,
the corporate guarantor, or
business combination, (e.g. the consolidated or combined financial statements of the buyer and one or more corporate
guarantors.).
Indicate which entities comprise the combination
Is the PSOR a financial institution?

Yes

No

Select the risk category of the PSOR:

Private sector

Does the PSOR have a bond rating?

Yes

Public sector

No

If yes, indicate the name of the rating agency, rating, and the date of the rating.
4. TRANSACTION DESCRIPTION AND ELIGIBILITY
Indicate whether the sale represents a:
Firm order

Sale in Negotiations

Response to an invitation to Bid

Provide a description of the products or service, including their NAICs code, if known:

Regarding the above products or services…
1.
2.
3.
4.
5.

Is each product produced or manufactured in the United States?
Yes
No
Are these products on the munitions control list?
Yes
No
Are the products new or used?
New
Used
Are the products capital goods that will be used to produce exportable products?
Yes
No
(a) For SBA Defined Small Business Only: 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) with no value added after shipment? Yes
No
(b) If the answer to 5(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 5(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 Sheet for information on
aggregation). Please indicate if you are seeking coverage on an aggregated basis. Yes
No
* PLEASE NOTE THAT YOU MAY ANSWER “YES” TO EITHER OR BOTH (b) AND (c) ABOVE.

6.

(d) For Non-SBA Defined Small Business: 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) with no
value added after shipment? Yes No
Will any value be added to the product after export from the U.S.?
Yes
No
If yes, provide an explanation:

7.

Has the transaction been considered by any other export credit insurer? Yes

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No

If yes, provide an explanation:

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5. FINANCED AMOUNTS AND STRUCTURE
Enter the %s for each payment term the exporter will extend to the buyer
(e) Payment terms requested
Payment Type

(number of days)
Sight

Up to
30

Up to
60

Please check applicable box
Up
Up
Up to
Up to
to
to
90
270
120
180

Up to
360

Cash Against Documents (CAD)
Sight Draft Documents Against Payment (SDDP)
Unconfirmed Irrevocable Letter of Credit (UILC)
Open Account
Sight Draft Documents Against Acceptance (SDDA)
Promissory Note

Number of shipments:
single
multiple under one sales contract
Expected date(s) of shipment:
Estimated shipment volume to be insured:
If multiple shipments, the expected highest amount outstanding during the shipment period:
Other security available:
6. CREDIT INFORMATION ON THE PSOR
The information requested in Attachment I: Credit Information is attached.
7. NOTICES AND CERTIFICATIONS
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)

2)
3)
4)
5)

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”);
formally proposed for debarment from participating in a Covered Transaction, with a final determination still pending;
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;
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
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.

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B. Applicant has conducted and will conduct reasonable due diligence in connection with this transaction, including checking the
Excluded Parties List System (http://www.epls.gov/epls/search.do) (“EPLS”) 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 EPLS or the SDN List (or is otherwise prohibited from conducting business with U.S. public
and private entities pursuant to OFAC Regulations).
C. Either: (1)To the best of Applicant’s knowledge and belief, no funds have been paid or will be paid to
any person in connection with this application for influencing or attempting to influence:
(a) an officer or employee of any U.S. Government agency, or
(b) a Member of Congress or a Member’s employee, or
(c) an officer or employee of Congress;
(This does not apply to commissions paid by the Bank to insurance brokers.)
or
(2) Applicant will complete and submit Form-LLL (the Anti-Lobbying Declaration/Disclosure forms available at
http://www.exim.gov/pub/ins/pdf/lll.pdf
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

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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 1.5 hours to complete this form. This 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 # 3048-0018 Washington, D.C. 20503.

Applicant (Exporter) name:
Name and title of authorized officer:
Signature of Authorized officer:
Date:

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Attachment I: Credit Information Requirements
Directions: The required credit information depends on whether the PSOR is the buyer or corporate guarantor, or a financial
institution guarantor and on the amount of credit support requested. Check the boxes that are applicable to your transaction.
1.

The PSOR is not a financial institution:

a) Provide details of the exporter’s experience with the buyer
Does the exporter have any experience selling to the buyer?
If yes, provide the following information:
Date of first sale to the buyer:
Date of first credit sale to the buyer:
Historic credit experience with the buyer:
Yearly Credit
Experience
Total amount sold
Total amount on
credit
Highest amount
outstanding for
which exporter
has been paid
Payment
terms/tenor

Current Year

Amount now owing:
Payment history:
prompt

Yes

No

Prior year 1

1 – 30 days slow

31 – 60 days slow

Prior year 2

more than 60 days slow

Is there an amount past due?
Yes
No
If yes, enter amount due and due dates.
Provide reasons for past dues:
If past dues were due to foreign exchange problems, does applicant have evidence of local currency deposits on all payments
due?
Yes
No
b) Provide the applicable supporting financial information on the PSOR. Check the box that applies to your transaction and
provide the information noted below the box
The transaction is for an amount up to $50,000:
•

credit agency report or trade reference or applicant’s ledger experience

The transaction is between $50, 001 and $100, 000:
•

credit agency report and trade reference or applicant’s ledger experience

The transaction is between $100,001 and $300, 000:
•
•
•

credit agency report,
two trade references or one trade reference and applicant’s ledger experience, or
two most recent years signed fiscal year-end statements

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Attachment I: Credit Information Requirements
The transaction is between $300, 001 and $ 1,000,000:
•
•
•

credit agency report
two trade references
audited or signed, unaudited financial statements for the last two fiscal years that adequately disclose financial condition
and afford a reasonable basis for reliance on the information provided.

The transaction is between $1,000,001 - $10,000,000
•
•
•
•

2.

credit agency report
two trade references
bank reference
audited financial statements for the last three fiscal years that adequately disclose financial condition
and afford a reasonable basis for reliance on the information provided.

The PSOR is the financial institution guarantor.
a. Provide details of the exporter’s experience with the financial institution guarantor. Include dates and amounts of
previous transactions with the PSOR or indicate
None

b. Provide supporting financial information.
Check the box that applies to your transaction and provide the information noted below the box
The transaction is for an amount up to $1 million:
•
•

One favorable reference from creditor bank.
One short-term debt rating of the PSOR from S & P, Moody’s or Fitch IBCA. Ratings must be B, P-3 or F3 or better,
respectively.

•

Most recently published fiscal year end or interim statements or statement spreads from Fitch IBCA, or Bankscope.

OR

The transaction is for between $1,000,001 and $10,000,000
•
•

One favorable reference from a creditor bank
If the PSOR does not have an acceptable current market rating, provide most recently published audited financial
statements that adequately disclose financial condition and were prepared in accordance with to accounting principles
that afford a reasonable basis for reliance on the information provided.

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Attachment II
Pre-shipment Questionnaire
Details of Coverage Requested
a) Provide the reason pre-shipment coverage is requested
b) Indicate the date the contract was executed or the anticipated date of signing
c) Indicate the estimated period between the contract date and the final shipment date
d) Provide a schedule of any progress payments made or to be made by the buyer or during the pre-shipment period,
or indicate none:

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Attachment III. Enhanced Assignment Questionnaire
If requesting Enhanced Assignment, attach
•
•
•

A bank reference on the exporter/applicant dated within six months of the application
Two trade references dated within six months of the application
Financial statements on the exporter/applicant as follows, for a policy limit of liability of:
o $500,000 or less CPA compiled financial statement for two most recent fiscal years
o $500,001 - $999,999 reviewed by a CPA with notes attached
o $1,000,000 or more audited by a CPA with opinion and notes attached

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Attachment IV Additional Named Insured Questionnaire
Legal Name:
Contact:
Address:
City:
State:
Country:
Nine Digit Zip/ Postal Code:
Relationship to Applicant:
Contact:
Role in the transaction:
E-mail:
Contact person:

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Attachment V – Warehouse Information
If you requested the Special Coverage – Warehouse, answer the following questions about the warehouse
Warehouse Type:

Owned or controlled by exporter
Bonded warehouse
Neither

Warehouse Location: City
State/Province
Country

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