Form 50 Registration for Political Risk Insurance

CONFIDENTIAL COMMERCIAL INFORMATION

Request for Registration For Political Risk Insurance (Form 50) OMB No: 3420-0038 Expiration Date: Overseas Private Investment Corporation 1100 New York Avenue, NW Washington, DC 20527-0001 An Agency of the United States Government
This form is to be used in registering proposed investment projects for OPIC political risk investment insurance. To ensure that the project remains eligible for OPIC insurance, you should submit this form to OPIC prior to making an irrevocable investment commitment. OPIC will not accept the registration for investments irrevocably committed prior to the date of your request. There is no fee for registering a project for OPIC insurance. Upon acceptance of this request, you will receive a notification from OPIC acknowledging that your project has been registered. The notification does not commit OPIC to providing political risk insurance, nor does registration commit the applicant to purchasing OPIC insurance. For insurance to be issued, the investor must submit a formal application for insurance (wherein the information submitted in this registration form may be amended) and the investment must meet all statutory and policy requirements. 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.  This is a voluntary information collection. The public reporting burden for this collection of information is estimated to average 30 minutes 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 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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Part 1: Investor Information

1.

Investor:

     

Contact:

     

Title:

     

Address:

     

City:

     

State:

     

Zip/Postal Code:

     

Country:

     

Telephone:

     

Fax:

     

E-Mail:

     

Web site:

     

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)

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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)

Will you have a contract with the host government to provide these products or services?

Yes

No

(c)

The enterprise you will be investing in is:

New

An existing business to be expanded or improved.

(d)

Does the host government have any investment in the enterprise?

Yes

No

If Yes, the host government owns:

________%

(e)

Could this project result in reduced U.S. employment?

Yes

No

(f)

Could this project result in significant adverse environmental impacts?

Yes

No

Part 3: Investment to be Made

6.

Investment to be Made

(a)

Total amount of investment :

$      

(b)

Estimated date of investment:

     

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(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.      

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(d)

What do you plan to insure?

Investors

Contractors & Exporters

Equity

Loan Guaranty

Bid Bond

Contract Disputes

Debt

Technical Assistance

Assets

Performance/Advance Payment Guaranties

Lease

Other

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:

     

State:

     

Zip/Postal Code:

     

Country:

     

Telephone:

     

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.

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

Part 5: Signature
	Investor Signature:			Date:	     

OPIC-50

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