Application to conclude a trade credit insurance contract

* Compulsory fields

Company name *

Head office address *

Registration address *

Company code *

VAT payer's code

Number/date of issue of the company's registration certificate

Description of activities *

Sectors of buyers' activities

Associated companies

Company's payment account *

Bank

Person responsible for credit management (contact person) *

Position *

Telephone *

Mobile telephone

Fax

Email *

Information about company's owners

Name, surname / Company name

Portion of shares (%)

Table of buyer outstandings' analysis

Current outstandings (until the expiry of the credit period) *

100.00%

Outstandings overdue by 1-90 days (after the expiry of the credit period) *

100.00%

Outstandings overdue by more than 90 days (after the expiry of the credit period) *

100.00%

Distribution of buyers' outstandings (as of the end of the last reporting period)

up to 1,000 *

100.00%

from 1,001 to 5,000 *

100.00%

from 5,001 to 10,000 *

100.00%

from 10,001 to 15,000 *

100.00%

from 15,001 to 20,000 *

100.00%

More than 20,000 *

100.00%

Analysis of bad debts

QUANTITY *

AMOUNT *

Name of the buyer *

Country of the buyer *

Amount of bad debt *

Year

Add document/s

Table of insurable turnover

Insurable 12-month turnover in domestic market *

100.00%

Insurable 12-month export turnover *

100.00%

Distribution of sales by countries

Buyer's country

Insurable turnover over 12 months *

% share

Number of buyers

Maximum

Medium

10 biggest buyers

Buyer's name

Buyer's address

Buyer's country

Buyer's code

Credit limit *

Max CP (d.) **

Assessments of the buyers above will be invoiced at the inception of the Contract under the terms of the Contract.

Do you presently insure trade credits?

Yes

Name of insurance company

Insurance contract (policy) validity date (from)

Insurance contract (policy) validity date (to)

Do you sell dual-use products or services? *

Have you obtained the necessary permits, required for the sales of dual-use products or services?* *

Yes

Are you going to use the services of an insurance broker? *

Yes

If yes, please specify the name of the insurance broker