Form DFC‐002 Request for Registration for Political Risk Insurance

CONFIDENTIAL COMMERCIAL INFORMATION

Request for Registration for Political Risk
Insurance (DFC-002)
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 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, 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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CONFIDENTIAL COMMERCIAL INFORMATION

Part 1: Investor(s) Information
1. Investor*:
Contact Name:

Title:

Address:
City:

State:

Country:

Telephone:

E-Mail:

Web site:

Zip/Postal Code:

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 citizen of [__________________]; or
A company organized in [__________________].
3. How did you hear about DFC?
DFC sponsored
workshop or event

DFC speaker at an
industry event

DFC Web site or other social
media (Facebook, Twitter,
LinkedIn)
Insurance Broker

Other US Government Agency (e.g.
State/Embassy, Commerce, Treasury, TDA,
SBA, USEXIM, etc.)
Current or former DFC clients

Other (please specify)
*[Note to Forms Portal and Insight Programmers: Please add ability for additional investors to complete this question]

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CONFIDENTIAL COMMERCIAL INFORMATION

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:
An existing business to be expanded or improved.
New
(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 significant adverse impact on 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:
(c) Has any portion of this investment been made or irrevocably committed as of the date of registration?
Yes
(d) Total project cost:

No

If yes, please explain and indicate when the investment was made.
$__________________

*The DFC does not support projects that outsource U.S. jobs or relocate existing U.S. facilities.

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CONFIDENTIAL COMMERCIAL INFORMATION

(e) What do you plan to insure?
Investors
Equity
Loan Guaranty
Debt
Technical Assistance
Lease
Other

Bid Bond
Assets
Other

Contractors & Exporters
Contract Disputes
Performance/Advance Payment Guaranties

Part 4: Insurance Broker, Primary Insurer, Reinsurer, or Agent
7. This registration is being submitted:
By the Investor
OR
By the Primary Insurer or Reinsurer
OR
By a licensed insurance broker or broker
agency
OR
By an agent*
Contact:

Title:

Address:
City:

State:

Country:

Telephone:

Zip/Postal Code:

E-Mail:
*An agent assists the investor 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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CONFIDENTIAL COMMERCIAL INFORMATION

8. Who will complete the DFC insurance application (Form 003)?
Investor
Primary Insurer
Licensed insurance broker or brokerage agency
Agent

Part 5: Signature
Investor Signature:

Date:

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