Form OPIC-52 Application for Political Risk Insurance

FOR  REFERENCE  ONLY  –  THIS  FORM  IS  TO  BE  COMPLETED 
ONLINE – PAPER SUBMISSIONS WILL NOT BE ACCEPTED 

Application for Political Risk Insurance
(Form 52)
OMB No.: 3420-0011
Expiration Date:

Overseas Private Investment Corporation
1100 New York Avenue, NW Washington, DC 20527-0001
An Agency of the United States Government

NOTICE: This form requests from potential OPIC clients information that is required by OPIC’s governing legislation - the Foreign
Assistance Act of 1961, Title IV, as amended (“FAA”) - to assist OPIC in determining whether applicants meet eligibility criteria for
OPIC political risk insurance. Complete responses to the questions on this form are required to apply for OPIC insurance benefits
under the FAA.
Responses to questions which call for estimates or projections should take the form of good faith statements made to the best of the
applicant’s knowledge and belief. Statements of fact provided to OPIC in this document must be accurate as of the date of execution
of this document. In addition to other rights and remedies available to OPIC, misrepresentations or failure to disclose relevant
information may result in criminal prosecution pursuant to 22 USC 2197(n), as well as cancellation of insurance if a policy is issued.
Neither submission nor acceptance of this application implies that the project is eligible for insurance or that insurance will be
provided.
Client information contained in this form will be deemed designated as confidential commercial information in accordance with
OPIC's Freedom of Information Act (FOIA) regulations (22 CFR 706), and will be treated as confidential commercial information to
the extent permitted by applicable law. As a federal agency, OPIC may not collect, or sponsor the collection of, information unless it
displays a valid OMB Control Number with an expiration date that has not expired.
Paperwork Reduction Act Notice: This information is required to obtain benefits. The public reporting burden for this collection
of information is estimated to average 9 hours per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing
this burden, to Agency Clearance Officer, 1100 New York Ave., NW, Washington, DC, 20527 and Regulatory Affairs, Office of
Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503.

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Application for Political Risk Insurance
(Form 52)

INSTRUCTIONS:
1. All applicants must fill out a complete application
2. All applicants must provide the certifications requested
3. If you use an attachment to answer any of the questions in this application, please write “see
Attachment” in the appropriate answer block and indicate the corresponding question number on your
attachment.
4. All applicants applying for OPIC insurance must sign this application. If an Investor is applying for
OPIC insurance on behalf of other eligible Investors, OPIC also will require the ultimate beneficiary
Investors to sign this application.

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QUESTION 1: Identify the Investor
Name of Investor:
OPIC Insurance Registration Number:
(See OPIC registration notification for assigned number.)

Address:
City:
State:
Zip/Postal Code:
Country:
Telephone:
Fax:
E-Mail:
Website:
Occupation (if individual):
Location of registration/incorporation (if entity):
DUNS number:

QUESTION 2 (for each investor listed above): Type of Investor (check one investor type only)
___ Entity Organized Under U.S. Law
Is more than 50% of both the total equity interest and each class of equity interests issued by
__ the Investor and outstanding on the date hereof beneficially owned by U.S. citizens? (If No,
please contact OPIC before proceeding.)

__ Is this entity a minority-owned business?
__ Is this entity a women-owned business?
___ Individual Investor
__ Is the Investor a citizen of the United States? (If No, please contact OPIC before proceeding.)
___ Entity Organized Outside of the United States
If organized other than as a corporation, is 100% of both the total equity interest and each
__ class of shares or equity interests issued by the Investor and outstanding beneficially owned by
U.S. citizens? (If No, please contact OPIC before proceeding.)
If organized as a corporation, is 95% or more of both the total equity interest and each class of
__ shares or equity interests issued by the Investor and outstanding beneficially owned U.S.
citizens? (If No, please contact OPIC before proceeding.)
___ Non-Profit/Non-Governmental Organization organized under U.S. Law
__ Is more than 50% of the Board of Directors composed of U.S. citizens?
___ Non-Profit/Non-Governmental Organization organized outside of the U.S.
__ Is 100% of the Board of Directors composed of U.S. citizens?
* OPIC deems a corporation organized under the laws of the U.S. or its states or territories to be beneficially owned by U.S. citizens
if more than 50 percent of each class of its issued and outstanding stock is owned by U.S. citizens either directly or beneficially

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QUESTION 3: Identify the Authorized Representative
Name of Person OPIC should contact for information:
Title:
Company:
Address:
City:
State:
Zip/Postal Code:
Country:
Telephone:
Fax:
E-Mail:

QUESTION 4: How Did You Learn About OPIC and its Services?
___ OPIC Web site or other social media (Facebook, Twitter, etc.)
___ OPIC sponsored workshop or event
___ OPIC speaker at an industry event
___ Other government agency (e.g. State/Embassy, Commerce, Treasury, TDA, SBA, USEXIM, etc.)
___ Insurance broker
___ Current or former OPIC clients
___ Other (please explain)

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OPIC strongly encourages Investors to consider carefully the availability of private political risk insurance for
their investments abroad. OPIC only offers insurance to Investors who, having investigated the possibility of
obtaining insurance from private political risk insurers, decide to pursue OPIC insurance because private
insurance is not available on terms sufficient to make the investment viable for the Investor, or because of
specific benefits OPIC participation will bring to the investment.
QUESTION 5: Have you sought political risk insurance from the U.S. private political risk insurance
market for the project?
___ Yes
___ No

QUESTION 6a: If private political risk insurance is available, is it in the amount necessary and on terms
sufficient for the project’s viability?
___ Yes
___ No

QUESTION 6b: If Yes, please explain why political risk insurance is being sought from OPIC. If No,
please explain.

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QUESTION 7: Project Description
•

Briefly describe the project and investment structure.

•

Please attach a copy of information memoranda, business plans, investment structure diagram or
other descriptions of the project that would be helpful to OPIC’s understanding of the project.
Also provide copies of any project documentation such as company charter, joint venture
documents, loan agreements, technical assistance agreements, management service agreements,
lease agreements, loan guaranties, licenses or agreements with the host government, etc. All
documentation must be in English.

•

If entering into a contract to provide goods/services to a foreign government, please indicate total
amount, date contract was/will be signed, and approximate date work will commence. Please
attach a copy of the contract as well.

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QUESTION 8: Please specify whether this project is:
___ An expansion of an existing enterprise
___ A new (greenfield) enterprise
___ A privatization of a state-owned company
___ Other (please explain)

QUESTION 9: Where is the project located? (If in a remote location, please include GPS coordinates or
attach a map showing the location.)

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QUESTION 10: Name of the entity (the “Foreign Enterprise”) in the host country into which the
investment will be made:
Foreign Enterprise:
Address:
City:
Postal Code:
Country:
Telephone:
Fax:
E-Mail:

QUESTION 11: Government Involvement
•

•

Describe any host government involvement in the project such as any contracts, concession, or licenses
from the government, any planned government purchasing or supplying, or any form of joint venture
with the government.

If entering into a contract to provide goods/services to a foreign government, give the name and
address of the department or agency involved. Briefly describe any previous experience the Investor
has had with this foreign government.

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QUESTION 12: Current and Past Disputes
Please identify and describe briefly any current or past disputes with respect to this project that
involve any agency or instrumentality of the host government. Include all disputes that involved or
currently involve the Investor, the Foreign Enterprise, or any participants in the project.

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QUESTION 13: Type of Investment to be Insured (check all that apply)
__ Equity

$

__ Leases

$

__ Loans or Loan Guaranties

$

__ Technical Assistance or Management Agreements

$

__ Performance Guaranty/Advance Payment
Guaranty/Other Guaranty/Contract Disputes

$

__ Other (please explain)

$

QUESTION 14: Type of Coverage Sought (Check all that apply)
__
_
__
_
__
_
__
_
__
_
__
_

Expropriation
Political Violence for Assets
Non-Honoring of a Sovereign Guarantee*
Inconvertibility
Political Violence for Business Income
Wrongful Calling of a Guaranty (Bid bonds, advance payment, etc.)
(If seeking coverage for wrongful calling of a guaranty, please provide draft/final copy of each of the guaranties you wish to
insure).

* Please consult with OPIC regarding specific eligibility requirements for this coverage before proceeding.

QUESTION 15: Term of OPIC Contract:
years

(OPIC can offer a minimum term of 3 years
and a maximum term of 20 years)

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QUESTION 16: Investment Schedule

Date

Amount

Initial Investment
Subsequent Investments

Expected date that commercial
operations will begin

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OPIC seeks to ensure that American insurance companies have an opportunity to compete for transportation
insurance business associated with the export of goods to projects supported by OPIC programs. To encourage
fair and open competition for this business, OPIC requires certain certifications from investors receiving OPIC
insurance. Please complete section A, B, or C below, whichever is applicable.
A. No such certification is required if an Investor receiving OPIC insurance does not have a controlling
interest in fact in the Project Company.* If the Investor receiving OPIC insurance does not have a
controlling interest in fact in the Project Company, please check the box below.
□ The Investor receiving OPIC insurance does not have a controlling interest in fact in the Project Company.
B. In those instances where the Investor does have or will have a controlling interest in fact in the Project
Company, OPIC requires that the Investor certify that each contract for the export of goods from the United
States in connection with the establishment of the Project contain a clause requiring that United States
insurance companies have a fair and open competitive opportunity to provide insurance against risk of loss
for such export of goods. If the Investor is able to so certify, please check the box below.
□ The undersigned certifies that each contract for the export of goods from the United States in
connection with the establishment of the Project does have or will have a clause requiring that U.S.
insurance companies have a fair and open competitive bid opportunity to provide insurance against risk of
loss for such exports.
C. In those instances where the Investor does have or will have a controlling interest in fact in the Project
Company, but is unable to provide the certification requested immediately above, please check one of the
boxes below and provide details, explaining why you cannot do so at this time. In providing an explanation,
please make specific references, as applicable, to project country, legal or other impediments.
□ Laws of the project country prohibit use of American insurance services for transportation insurance.
□ There are no U.S. exports associated with the establishment of this Project.
□ All transportation insurance associated with the export of U.S. goods to the Project is or will be arranged
through the Investor’s worldwide insurance program. It is not practicable to alter these arrangements for
U.S. exports to the Project.
□ All transaction insurance associated with the export of U.S. goods to the Project is or will be arranged by
a Project participant who is other than the Investor under such Project participant’s insurance provider(s).
It is not practicable to alter these arrangements for U.S. exports to the Project.
□ Other (Please explain):

*Having a “controlling interest” means having possession, directly or indirectly, of the power to direct or
cause the direction of the management and policies of an entity, whether through the ownership of
partnership interests or voting security, by contract or otherwise.

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Each Investor must sign this application.
Applicant (Investor):

Applicant (Investor):

By:

By:

Name & Title (print):

Name & Title (print):

Date:

Date:

By signing this form, the Investor(s) hereby represents and warrants that (a) this form is identical in all material and
substantive respects to OMB form No. 3420 0011 sent to the Investor by OPIC and (b) that the Investor understands
that OPIC shall regard the Investor’s answers to the questions on this form to be answers to the questions as asked on
OMB form No. 3420 0011.

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