DFC-002 Request for Registration for Political Risk Insurance

CONFIDENTIAL COMMERCIAL INFORMATION

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

Request for Registration for Political Risk Insurance (DFC-002)

OMB No. 3015-0008

Expiration Date: 8/31/2022

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.

The Better Utilization of Investments Leading to Development (BUILD) Act of 2018 (P.L. 115-254) and the Inspector General Act of 1978 (P.L. 95-452) (as amended) (the “IG Act”) require DFC to have an Inspector General. The Office of the Inspector General’s mission is to provide independent oversight of DFC’s programs and operations for increased efficiency and effectiveness, and to prevent fraud, waste, and abuse. The Office of the Inspector General conducts audits, investigations, and other reviews of DFC programs, transactions, and operations.  The IG Act gives the Office of the Inspector General unrestricted access to all records in the possession and control of DFC, and requires that DFC provide the Office of the Inspector General unrestricted access to all DFC project data and systems in response to any request from the Office of the Inspector General. See 5 U.S.C. Appendix 3. The Office of the Inspector General may contact you, your organization, or your personnel in connection with an Office of the Inspector General audit, investigation, or other review and expects that you, your organization and your personnel will cooperate with requests for information from the Office of the Inspector General. More information about the Office of the Inspector General can be found here: https://www.dfc.gov/oig.

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.

Part 1: Investor(s) Information
1.	Investor*:
	Contact Name:	Title:
	Address:
	City:	State:	Zip/Postal Code1:
	Country:	Telephone:
	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 citizen of [ ]; or A company organized in [ ].
3.	How did you hear about DFC?
	DFC sponsored workshop or event	DFC Web site or other social media (Facebook, Twitter, LinkedIn)	Other US Government Agency (e.g. State/Embassy, Commerce, Treasury, TDA, SBA, USEXIM, etc.)
	DFC speaker at an industry event	Insurance Broker	Current or former DFC clients
	Other (please specify)

Part 2: Project Information

4. Where will the project be located?

^City: Country:

4. Please describe the project

   1. What products/services will be rendered?

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

Yes No

3. The enterprise you will be investing in is:

New ^{An existing business to be expanded or improved.}

4. Does the host government have any investment in the enterprise?

Yes No If Yes, the host government owns: ^%

5. Could this project result in significant adverse impact on U.S. employment*?

Yes No

6. Could this project result in significant adverse environmental impacts? Yes No

Part 3: Investment to be Made

6. Investment to be Made _$

   1. Total amount of investment :

   2. Estimated date of investment:

   3. 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.

   4. Total project cost: ^$

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

	(e)	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, 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:			Titl	e:
	Address:
		City:		State:	Zip/Postal Code:
	Country:			Telephone:
	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.

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:

1 For U.S. addresses, the zip code+4 is required for the postal code/zip code field in the address.

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