Form DFC‐003 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
(DFC-003)
OMB No. [
]
Expiration Date: _______

United States International Development Finance Corporation
1100 New York Avenue, NW Washington, DC 20527-0001
An Agency of the United States Government
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
in this document must be accurate as of the date of submission. Anyone who knowingly makes a
false statement with the intent to influence DFC’s guarantees, loans, or other investments may
be criminally prosecuted. Such false statements are also grounds for DFC to terminate a
commitment or declare a contract default. These rights are in addition to any other rights or
remedies available to United States government. Neither submission nor acceptance of this
application implies that the proposed transaction is eligible for support or that support will be
provided.
When trade secrets or confidential commercial or financial information are submitted to the
agency in this collection, they will be held in confidence to the extent permitted by applicable law
including the Freedom of Information Act (“FOIA”) at 5 U.S.C. § 552(b)(4) and the agency’s
implementing regulations at 22 C.F.R. Part 706.
Paperwork Reduction Act Notice: This information is required to obtain or retain benefits. Federal
agencies may not collect information unless a valid OMB Control Number with an expiration date
that has not expired is displayed. The public reporting burden for this collection of information is
estimated to average 3 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, Records Management, United States International Development
Corporation, 1100 New York Avenue, NW, Washington, DC, 20527 and to the DFC Desk Officer
at the Office of Information and Regulatory Affairs, Office of Management and Budget, New
Executive Office Building, Room 10202, Washington, DC 20503.

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Application for Political Risk Insurance
(Form 003)
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 DFC insurance must sign this application. If an Investor is applying for DFC
insurance on behalf of other eligible Investors, DFC also will require the ultimate beneficiary Investors to
sign this application.

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QUESTION 1: Identify the Investor(s)*
Name of Investor:
DFC Project ID:
(See Request for Registration for Political Risk Insurance (DFC Form 002))
Address:
City:
State:
Zip/Postal Code:
Country:
Telephone:
E-Mail:
Website:
Occupation (if individual):
Location of registration/incorporation (if entity):
DUNS number:
[*Note to Forms Portal and Insight Programmers: Please add ability for additional Investors to
complete this Question.]
QUESTION 2: Identify the Authorized Representative
Name of Person DFC should contact for information:
Title:
Company:
Address:
City:
State:
Zip/Postal Code:
Country:
Telephone:
E-Mail:

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DFC strongly encourages Investors to consider carefully the availability of private political risk
insurance for their investments abroad. DFC only offers insurance to Investors who, having
investigated the possibility of obtaining insurance from private political risk insurers, decide to pursue
DFC insurance because private insurance is not available on terms sufficient to make the investment
viable for the Investor, or because of specific benefits DFC participation will bring to the investment.
QUESTION 3: Have you sought political risk insurance from the private political risk insurance
market for the project?
 Yes
 No

QUESTION 4a: 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 4b: If Yes, please explain why political risk insurance is being sought from DFC. If
No, please explain.

QUESTION 5: 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 DFC’s understanding of the project.
Please also include a description (or a copy) of the project’s plans for 1) environmental and
social due diligence, mitigation, and monitoring processes; 2) consultation with project-affected
communities (including disadvantaged and vulnerable groups); and 3) access to accountability
and remedy for negative project impacts on individuals and communities. 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.

QUESTION 6: 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 7: 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 8: Name of the entity (the “Foreign Enterprise”) in the host country into which the
investment will be made (if applicable):
Foreign Enterprise:
Address:
City:
Postal Code:
Country: Telephone:
E-Mail:

QUESTION 9: 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.

QUESTION 10: 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.

QUESTION 11: Type of Investment to be Insured (check all that apply)
 Equity

$ ______

 Leases

$ ______

 Loans or Loan Guaranties

$ ______

 Technical Assistance/Management/Supply/or Contractors and Exporters
Agreements

$ ______

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

$ ______

 Other (please explain)

$ ______

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QUESTION 12: Type of Coverage Sought (check all that apply)
 Expropriation (including Arbitral Award Default and Denial of Justice)
 Non-Honoring of a Sovereign Guarantee*
 Breach of Contract for Capital Markets
 Inconvertibility
 Political Violence - Assets
 Political Violence – Business Income
 Political Violence – Forced Abandonment
 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 DFC regarding specific eligibility requirements for this coverage before
proceeding.

Question 13: Term of DFC Contract: _____ years

QUESTION 14: Investment Schedule
Initial Investment

Date

Amount

Subsequent Investments

Expected date that commercial operations will
begin

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Each Investor must sign this application.

Applicant (Investor): ____________________

Applicant (Investor): ____________________

By: __________________________________

By: __________________________________

Name & Title (print) ____________________

Name & Title (print) _____________________

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. [ ] sent to the Investor by DFC and (b) that the
Investor understands that DFC shall regard the Investor’s answers to the questions on this form to be
answers to the questions as asked on OMB form No. [ ].
[*Note to Forms Portal and Insight Programmers: System should autofill Project ID on signature page, since the
signature page is submitted as a separate physical attachment to the completed application. That way, the
signature page can be related to the correct project file in the DFC’s electronic file system.]

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