Fillable APPLICATION FOR FINANCIAL INSTITUTION SHORT-TERM, SINGLE-BUYER INSURANCE (Export-Import Bank of the United States)

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APPLICATION FOR FINANCIAL INSTITUTION SHORT-TERM, SINGLE-BUYER INSURANCE (Export-Import Bank of the United States)

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OMB No. 3048-0019
Expires 08/31/2022
APPLICATION FOR FINANCIAL INSTITUTION
SHORT-TERM, SINGLE-BUYER INSURANCE
This application is to be completed by a Financial Institution (or a Broker acting on its behalf) in order to obtain a
Short-Term Insurance Policy covering transactions to a foreign Buyer. Repayment terms can be up to 360 days.
An online version of this application is available on EXIM’s web site. EXIM encourages customers to apply online,
to facilitate our review and allow customers a faster response time. Additional information on how to apply for
EXIM insurance can be found at EXIM’s web site www.exim.gov
Send this completed application to EXIM, 811 Vermont Ave NW, Washington, D.C. 20571. EXIM will also accept
E-mailed PDF and faxed applications. EXIM will not require the originals of these applications to be mailed. The
application must be PDF scan of the original application and all required documents.
(Fax number: 202.565.3380, E-mail: exim.applications@exim.gov)
APPLICATION FORM
Under corporate ownership, provide name of ultimate parent company, if there is a corporate owner.
Applicant/Lender
The applicant is the Financial Institution that extends the EXIM-insured loan to the Buyer. If your Financial
Institution is new to the FIBC program, please refer to the Short-Term Credit Standards for how to qualify as an
FIBC-insured Lender.
Applicant Legal Name: DUNS#:
Contact Person: Position Title: _____________________ E-mail:
Business Address: ____________________________________ City: _____________________ State/Province:
Postal Code: _____________________ Country: ________________Phone: _____________________Fax:
Broker
Name of Brokerage: Contact Person:
E-mail: Phone number: Fax:
W
oman-Owned:
Minority-Owned:
Veteran-Owned:
Yes
Yes
Yes
No
No
No
Decline to answer
Decline to answer
Decline to answer
1. GENERAL QUESTIONS
A. Coverage Types Requested
Risk coverage
Comprehensive Risk (political and commercial risk)
Political Risk (political risk only)
Is this a resubmission of an application that was previously deemed incomplete, was withdrawn for
other reasons, or are you requesting renewal for another policy?
Yes – please indicate previous transaction number:
No
B. Primary Reason for applying for this policy
Risk Mitigation
Financing
Extend more competitive terms
EIB 92-41 (Rev. 2/2019) Page 1 of 8
OMB No. 3048-0019
Expires 08/31/2022
2. SPECIAL COVERAGES
Check the applicable boxes in the table below for the special coverages that apply to this transaction and
provide related information in more detail in the relevant areas later in the application.
Bulk Agriculture Delivery to the Buyer in the
U.S.
Foreign Currency Coverage
Currency Requested: _____________
Overseas Warehouse
Coverage
Services (if exported item is a
service)
Other
3. PARTICIPANTS
Provide information on the additional participants to the transaction.
Exporter
The Exporter is the U.S. entity that contracts with the Buyer for the sale of the U.S. goods and services. Under
corporate ownership, provide name of ultimate parent company, if there is a corporate owner. For number of
employees and sales volume, aggregate the number for the company and all its affiliates
1
, including
corporate owners and subsidiaries.
Exporter's Legal Name:
Tradestyle:____________________________________________ Corporate Ownership:
Business Address: ____________________________________ City: _____________________ State:
Zip + 4:________________Country: ______________________
Primary Industry NAICS
2
:
Does the Exporter have Affiliates? Yes No
Total Number of Employees: Annual Sales Volume:
Contact Person: E-mail:
Position Title: Phone: Fax:
Woman-Owned:
Minority-Ow
ned:
Veteran-Owned:
Yes
Yes
Yes
No
No
No
Decline to answer
Decline to answer
Decline to answer
1
Affiliations exist when one individual or entity controls or has the power to control another or when a third party or parties control or have
the power to control both. Factors such as common ownership, common management, previous relationships with or ties to another entity,
and contractual relationships may cause affiliation. The complete definition of affiliation is found at 13 C.F.R. § 121.103.
2
A company’s Primary Industry NAICS codes is the NAICS that accounts for the largest share of sales for the most recently completed fiscal
year. The full definition of “primary industry” is set forth at 13 C.F.R. § 121.107.
EIB 92-41 (Rev. 2/2019) Page 2 of 8
OMB No. 3048-0019
Expires 08/31/2022
Supplier
The Supplier is the U.S. entity that manufactures the goods and/or performs the services to be exported. Check
if the Exporter is the Supplier and there are no additional Suppliers. Enter any additional Suppliers, or check
various:
Supplier's Legal Name:
Tradestyle: Corporate Ownership:
Business Address: _________________________________________________City:____________________ State:
Zip + 4: ________________________Country: ___________________________
Primary Industry NAICS:
Does the Exporter have Affiliates? Yes No
Total Number of Employees: Annual Sales Volume:
Contact person: E-mail:
Position Title: Phone: Fax:
Woman-Owned:
Yes No Decline to answer
Minority-Owned:
Yes No Decline to answer
Veteran-Owned:
Yes No Decline to answer
Buyer
The Buyer is the entity that contracts with the Exporter for the purchase of U.S. goods and services.
Buyer's Legal Name: __________________________________ Contact Person:
Position Title: _________________________________________ E-mail:
Business Address: ____________________________________ City: _____________________State/Province:
Postal Code: ________________ Country: ________________ Phone: Fax:
Guarantor
The Guarantor is the person or entity that agrees to repay the credit if the Buyer does not. Refer to the short-
term credit standards to determine in what circumstances personal or corporate Guarantors are required
for short-term transactions. Personal Corporate Financial
Guarantor's Legal Name: _____________________________ Contact Person:
Position Title: _________________________________________ E-mail:
Business Address: ____________________________________ City: _____________________State/Province:
Postal Code: ________________ Country: ________________ Phone: Fax:
End-User
The End-User is the foreign entity that uses the U.S. goods and services.
Check if the end-
user is also the Buyer:
End-User's Legal Name: _______________________________C
ontact Person:
Position Title: _________________________________________ E-mail:
Business Address: ____________________________________ City: _____________________State/Province:
Postal Code: ________________ Country: ________________ Phone: Fax:
EIB 92-41 (Rev. 2/2019) Page 3 of 8
OMB No. 3048-0019
Expires 08/31/2022
Agent
An agent is a business entity (corporation, partnership) or individual located in the country of the Borrower or
Buyer who assisted in the sourcing, packaging, and/or preparation of a request for support from EXIM, and
who will receive compensation in some form for their services.
Is an Agent involved in this transaction? Yes No If Yes, add the Agent information below:
Agent's Legal Name: __________________________________ Contact Person:
Position Title: _________________________________________ E-mail:
Business Address: ____________________________________ City: _____________________State/Province:
Postal Code: ________________ Country: ________________ Phone: Fax:
Related Parties
Describe any direct or indirect ownership interest or family relationship that exists between any of the
participants. If none, so indicate: none
Primary Source of Repayment (PSOR)
The PSOR is the entity whose financial statements form the basis of EXIM’s evaluation of reasonable assurance
of repayment, i.e. the entity whose financial statements EXIM uses to supply the numbers and calculate the
ratios for Short-Term Credit Standards compliance. For this transaction, indicate whether the PSOR is:
Buyer
Corporate guarantor, or
Business Combination, (e.g. the consolidated or combined financial statements of the Buyer and one or more
corporate Guarantors).
Indicate which entities comprise the combination:
Does the PSOR have a market rating?
Yes No
If yes, indicate the name of the rating agency, rating, type, outlook and the date of the rating.
4. TRANSACTION DESCRIPTION AND ELIGIBILITY
Provide a description of the products or service, including NAICS code, if known:
Answer the following questions about the products or services.
Is each product produced or manufactured in the U.S.?
Are the products shipped from the U.S.?
Will any value be added to the product post-export before delivery to the Buyer?
Are these products on the Munitions Control list?
Are these products sold to military entities of security forces?
EIB 92-41 (Rev. 2/2019)
Yes No
Yes No
Yes No
Yes No
Yes No
Page 4 of 8

OMB No. 3048-0019
Expires 08/31/2022
Are these used to support nuclear energy? Yes No
Are the products new or
used?
New Used
Are the products capital goods that will be used to produce exportable products?
Yes No
If Yes, provide an explanation:
Has this transaction been considered by any other export credit insurer?
Yes No
If yes, provide an explanation:
Do these products or their use meet EXIM’s requirements for an environmentally beneficial determination?
Yes No
If Yes, provide an explanation:
Do these products or their use meet EXIM’s requirements for a renewable energy determination?
Yes No
If Yes, provide an explanation:
5. FINANCED AMOUNTS AND STRUCTURE
What are the proposed terms to be offered under this facility?
Enter the details of the transaction below:
This application is for:
Single Financing Revolving Line of Credit
Indicate whether
the transaction is still being negotiated or the financing mandate has been received.
Credit Limit Requested: $
Requested Effective Date:
Repayment Terms:
6. Credit Information Requirements
Directions: The required credit information depends on the type of PSOR (non-financial institution or a financial
institution) and on the amount of credit support requested. Check the boxes that are applicable to your
transaction.
The PSOR is not a Financial Institution
Provide details of the Applicant’s experience with the Buyer:
Does the Applicant have any experience with the Buyer?
Yes No
EIB 92-41 (Rev. 2/2019) Page 5 of 8
OMB No. 3048-0019
Expires 08/31/2022
If Yes, provide the following information:
Date of first transaction with the Buyer:
Date of first credit transaction with the Buyer:
Has the Applicant visited the Buyer?
Yes No
If yes, indicate the date of the last visit and provide a call report:
Describe the credit facility type extended to the Buyer:
Short-Term – details:
Medium-Term – details:
Long-Term – details:
N/A
Total credit limit available to the Buyer/corporate Guarantor:
Total outstanding short-term lines of credit balances:
Total outstanding medium-term or long-term lines of credit balances:
Credit performance:
Satisfactory Unsatisfactory
Has the Applicant ever had credit insurance for the Buyer or Corporate Guarantor before?
Yes No
If yes, enter the name of the insurer, and coverage dates and amounts:
Please refer to the Short-Term Credit Standards found on our website to determine what information is
required in your application based on the dollar amount requested.
The PSOR is a Financial Institution
Provide details of the Applicant’s experience with the Financial Institution Guarantor. Include dates and
amounts of previous transactions with the PSOR or indicate if
none:
7. Overseas Warehouse Information (if applicable)
If you requested the Special Coverage - Overseas Warehouse, answer the following questions about the
warehouse:
Warehouse Type:
Owned or Controlled by Exporter
Bonded Warehouse
Neither - provide details
Warehouse Location: City
State/Province
Country
EIB 92-41 (Rev. 2/2019) Page 6 of 8
OMB No. 3048-0019
Expires 08/31/2022
8. Anti-Lobbying Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief, that:
If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or
employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with this commitment providing for the United States to insure or guarantee
a loan, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying,''
(available at www.exim.gov/sites/default/files/forms/lll.pdf) in accordance with its instructions. Submission of
this statement is a prerequisite for making or entering into this transaction imposed by section 1352, title 31,
U.S. Code. Any person who fails to file the required statement shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.
Signature ______________________________________________________
Title
EIB 92-41 (Rev. 2/2019) Page 7 of 8
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OMB No. 3048-0019
Expires 08/31/2022
CERTIFICATIONS AND SIGNATURE
Please refer to the “Standard Certifications and Covenants for EXIM Applications” set forth in Form EIB 18-CN,
posted on the EXIM website at https://www.exim.gov/tools-for-exporters/applications-forms/complete-list (the
“Standard Certifications”). THE STANDARD CERTIFICATIONS ARE INCORPORATED INTO THIS
APPLICATION AS IF FULLY AND DIRECTLY SET FORTH HEREIN. When signing this application in the
space provided below, the undersigned authorized officer signing on the applicant's behalf certifies and
represents that he or she is fully authorized to sign on the applicant's behalf, and that HE OR SHE HAS READ
the Standard Certifications referenced above AND IS CERTIFYING AND COVENANTING, as appropriate, to all
of the certifications, acknowledgments and covenants set forth in the Standard Certifications.
Applicant further certifies that the representations made and the facts stated in this application and its
attachments are true and Applicant has not misrepresented or omitted any material facts. Applicant further
covenants that if any statement set forth in this application or in the Standard Certifications, becomes untrue, or
is discovered to have been untrue when made, Applicant will promptly inform EXIM of all such changes or
discoveries. Applicant further understands that in accepting or approving this application, EXIM is relying upon
Applicant's statements set forth in the application and in the Standard Certifications, and all statements and
certifications to EXIM are subject to the penalties for false or misleading statements to the U.S. Government (18
USC § 1001, et. seq.).
I, , do hereby certify that I am the duly appointed and qualified
(Title)
of and that as such I am authorized to execute this application
(Name of Applicant)
on behalf of .
(Name of Applicant)
In witness whereof, I have hereunto signed my name this day of __ __ . 20 .
NOTICES
The applicant is hereby notified that information requested by this application is done so under authority of the Export-Import Bank Act of
1945, as amended (12 USC 635 et. seq.); provision of this information is mandatory and failure to provide the requested information may
result in EXIM being unable to determine eligibility for support. If any of the information provided in this application changes in any material
way or if any of the certifications made herein become untrue, the applicant must promptly inform EXIM of such changes. The information
provided will be reviewed to determine the participants’ ability to perform and pay under the transaction referenced in this application. EXIM
may not require the information and applicants are not required to provide information requested in this application unless a currently valid
OMB control number is displayed on this form (see upper right of each page). EXIM reserves the right to decline to process or to discontinue
processing of an application.
Paperwork Reduction Act Statement: We estimate that it will take you about 1.6 hour(s) to complete this form. This includes the time it will take to read
the instructions, gather the necessary facts and fill out the form. However, you are not required to provide information requested unless a valid OMB
control number is displayed on the form. If you have comments or suggestions regarding the above estimate or ways to simplify this form, forward
correspondence to EXIM and the Office of Management and Budget, Paperwork Reduction Project, OMB# 3048-0019 Washington, D.C. 20503.
EIB 92-41 (Rev. 2/2019) Page 8 of 8
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APPLICATION FOR FINANCIAL INSTITUTION SHORT-TERM, SINGLE-BUYER INSURANCE (Export-Import Bank of the United States)

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Completed 26 January 2021

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