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Application Trade Credit Insurance (Chubb)

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Country of origin: UK
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Page 1 of 10
Application – Trade Credit Insurance
Multi Buyer
The info
rmation provided in this Application will be treated in the strictest confidence and, if fully completed, will
enable us to assess your risks and determine whether we can indicate terms.
In the event that we issue a Policy to you, this Application form, any attachments and additional information
(oral and written) you have provided to us, shall form the basis of the Policy.
1.
APPLICANT’S DETAILS
Company Name:
Address: Zip Code:
Contact name: Position:
Tel. No.: E-mail:
Is cover required for any other group company? □ Yes □ No
If yes, please provide full details: ____________________________________________________________________
2.
LOSS PAYEE (If Applicable)
Please provide the following details of the company that you want to receive payment in the event of a claim:
Company Name:
Address: Zip Code:
Contact name: Position:
Tel. No.: E-mail:
3. BUSINESS ACTIVITIES
What kind of goods / services do you sell (Goods Insured)? ______________________________________________
To which trade sector do you sell them? ______________________________________________________________
What is the period from date of contract to date of shipment? ____________________________________________
Do you manufacture the goods that you sell? □ Yes □ No
What are your normal terms of payment? _____________________________________________________________
Chubb Global Markets Political Risk & Credit
1133 Avenue of the Americas New York, NY 10036
(212) 835-3138 (NY)
(312) 612-8827 (Chicago)
(213) 612-5512 (Los Angeles)
Page 2 of 10
What extended terms of payment do you sell on? ______________________________________________________
What is your average Days’ Sales Outstanding?
Is your business seasonal? □ Yes □ No
If yes, please provide details: _______________________________________________________________________
Do you require any special features of cover (e.g. consignment stock)? ____________________________________
_________________________________________________________________________________________________
4.
OTHER CREDIT INSURANCE POLICIES, GUARANTEES, SECURITIES
Do you at present hold any credit insurance policy, guarantees or security in connection with the credit risk on any of
your Buyers? □ Yes □ No
If yes, what is it? __________________________________________________________________________________
_________________________________________________________________________________________________
Do you factor, discount or otherwise assign your debts? □ Yes □ No
If yes, please provide details: _______________________________________________________________________
_________________________________________________________________________________________________
Have you ever had an insurance policy cancelled or a renewal refused by an insurer?
□ Yes □ No
If yes, please provide details: _______________________________________________________________________
_________________________________________________________________________________________________
5.
PAST EXPERIENCE (please state currency if not US$)
Financial Year Ending
Month / Year
Sales Losses* Largest Individual Loss Number of
Losses
* Please indicate if Losses given are (a) arising from shipments made during the year, or (b) in respect of losses occurring during
the year. Please do not give write-offs made during the year.
Page 3 of 9
Please provide details of largest individual losses:
Financial Year Ending
Month / Year
Name of Buyer Cause of Loss
6. ACCOUNTS RECEIVABLE BALANCES (please state currency if not US$)
As at last:
31 March ___________________________________________ 30 June_____________________________________
30 September _______________________________________ 31 December ________________________________
7.
CURRENT AGED ACCOUNTS RECEIVABLE ANALYSIS (please state currency if not US$)
As at: ______________________________________________
Range Total debt outstanding
Current (not yet due)
1-30 days past due date
31-60 days past due date
61-90 days past due date
Over 90 days past due date
8. BUYER PROFILE (please state currency if not US$, and amend the range values if appropriate)
As at: ______________________________________________
Range Total debt
outstanding
Number of
Buyers
Range Total debt
outstanding
Number of
Buyers
0 – 5,000
75,001 – 100,000
5,001 – 10,000
100,001 – 250,000
10,001 – 25,000
250,001 – 500,000
25,001 – 50,000
500,001 – 1,000,000
50,001 – 75,000
1,000,000 +
Page 4 of 9
9. PROJECTED SALES DETAILS (please state currency if not US$)
Please provide details of your projected sales excluding the following: sales to any associated or subsidiary companies;
government departments, public authorities or nationalized undertakings except where you require coverage in respect
of Public Buyer Default.
Period From: _____________________________________________ to: ____________________________________
Country Estimated
Sales
Maximum Exposure
at any one time
No. of Buyers Terms of
Payment
Please continue on a separate sheet if necessary
Page 5 of 9
10. PRINCIPAL BUYERS (please state currency if not US$)
Name & Address Credit Limit
Required
Annual Sales Terms of
Payment
Please continue on a separate sheet if necessary
Page 6 of 9
11. LIST OF ACCOUNTS MORE THAN 60 DAYS OVERDUE, ACCOUNTS GIVING CAUSE FOR CONCERN AND/OR
WHERE DELIVERIES HAVE BEEN STOPPED
As at: ______________________________________________
Name & Address Amount
Outstanding
Original due date Action taken
Please continue on a separate sheet if necessary
12.
CREDIT PROCEDURES
We require a fully completed ACE Credit Procedures Questionnaire before a Policy can be issued.
Do you have a credit procedures manual? Yes No
If yes, please attach. Attached
13.
FRAUD STATEMENTS
FRAUD WARNING STATEMENTS (ALL STATES)
NOTICE TO ARKANSAS APPLICANTS: Any person who
knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a
crime and may be subject to fines and confinement in
prison.
NOTICE TO COLORADO APPLICANTS: It is unlawful to
knowingly provide false, incomplete, or misleading facts
or information to an insurance company for the purpose
of defrauding or attempting to defraud the company.
Penalties may include imprisonment, fines, denial of
insurance, and civil damages. Any insurance company
or agent of an insurance company who knowingly
provides false, incomplete, or misleading facts or
information to a policyholder or claimant for the purpose
of defrauding or attempting to defraud the policyholder
or claimant with regard to a settlement or award
payable from insurance proceeds shall be reported to
the Colorado Division of Insurance within the
Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS:
WARNING: It is a crime to provide false or misleading
information to an insurer for the purpose of defrauding
the insurer or any other person. Penalties include
imprisonment and/or fines. In addition, an insurer may
deny insurance benefits if false information materially
related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who
knowingly and with intent to injure, defraud or deceive
Page 7 of 9
any insurer files a statement of claim or an application
containing any false, incomplete or misleading
information is guilty of a felony of the third degree.
NOTICE TO KENTUCKY APPLICANTS: Any person
who knowingly and with intent to defraud any insurance
company or other person files an application for
insurance containing any materially false information or
conceals, for the purpose of misleading, information
concerning any fact material thereto commits a
fraudulent insurance act, which is a crime.
NOTICE TO LOUISIANA APPLICANTS: Any person
who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a
crime and may be subject to fines and confinement in
prison.
NOTICE TO MAINE APPLICANTS: It is a crime to
knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of
defrauding the company. Penalties may include
imprisonment, fines or a denial of insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person
who knowingly and wilfully presents a false or
fraudulent claim for payment of a loss or benefit or who
knowingly and wilfully presents false information in an
application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
NOTICE TO NEW JERSEY APPLICANTS: Any person
who includes any false or misleading information on an
application for an insurance policy is subject to criminal
and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person
who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a
crime and may be subject to civil fines and criminal
penalties.
NOTICE TO NEW YORK APPLICANTS: Any person
who knowingly and with intent to defraud any insurance
company or other person files an application for
insurance or statement of claim containing any
materially false information, or conceals for the purpose
of misleading, information concerning any fact material
thereto, commits a fraudulent insurance act, which is a
crime, and shall also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the
claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with
intent to defraud or knowing that he is facilitating a
fraud against an insurer, submits an application or files
a claim containing a false or deceptive statement is
guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING:
Any person who knowingly, and with intent to injure,
defraud or deceive any insurer, makes any claim for the
proceeds of an insurance policy containing any false,
incomplete or misleading information is guilty of a
felony.
NOTICE TO OREGON APPLICANTS: Any person who
knowingly and with intent to defraud any insurance
company or another person, files an application for
insurance or statement of claim containing any
materially false information, or conceals information for
the purpose of misleading, commits a fraudulent
insurance act, which may be a crime and may subject
such person to criminal and civil penalties.
NOTICE TO PENNSYLVANIA APPLICANTS: Any
person who knowingly and with intent to defraud any
insurance company or other person files an application
for insurance or statement of claim containing any
materially false information or conceals for the purpose
of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a
crime and subjects such person to criminal and civil
penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to
knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of
defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to
knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of
defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.
NOTICE TO WASHINGTON APPLICANTS: It is a crime
to knowingly provide false, incomplete, or misleading
information to an insurance company for the purposes
of defrauding the company. Penalties include
imprisonment, fines, and denial of insurance benefits.
NOTICE TO WEST VIRGINIA APPLICANTS: Any
person who knowingly presents a false or fraudulent
claim for payment of a loss or benefit or knowingly
presents false information in an application for
insurance is guilty of a crime and may be subject to
fines and confinement in prison.
NOTICE TO ALL OTHER APPLICANTS:
ANY PERSON WHO KNOWINGLY AND WITH INTENT
TO DEFRAUD ANY INSURANCE COMPANY OR
ANOTHER PERSON, FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM
CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS INFORMATION FOR
Page 8 of 9
THE PURPOSE OF MISLEADING, COMMITS A
FRAUDULENT INSURANCE ACT, WHICH IS A CRIME
AND MAY SUBJECT SUCH PERSON TO CRIMINAL
AND CIVIL PENALTIES.
FRAUD WARNING STATEMENTS (WARRANTY
STATES ONLY – AR, CA, CO, CT, DC, IA, IL, IN, LA,
MA, MD, MI, MN, MO, MS, ND, NE, NJ, NM, NY, OH,
OK, RI, SC, TN, TX, UT, VT, WA and WI)
NOTICE TO ARKANSAS APPLICANTS: Any person who
knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a
crime and may be subject to fines and confinement in
prison.
NOTICE TO COLORADO APPLICANTS: It is unlawful to
knowingly provide false, incomplete, or misleading facts
or information to an insurance company for the purpose
of defrauding or attempting to defraud the company.
Penalties may include imprisonment, fines, denial of
insurance, and civil damages. Any insurance company
or agent of an insurance company who knowingly
provides false, incomplete, or misleading facts or
information to a policyholder or claimant for the purpose
of defrauding or attempting to defraud the policyholder
or claimant with regard to a settlement or award
payable from insurance proceeds shall be reported to
the Colorado Division of Insurance within the
Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS:
WARNING: It is a crime to provide false or misleading
information to an insurer for the purpose of defrauding
the insurer or any other person. Penalties include
imprisonment and/or fines. In addition, an insurer may
deny insurance benefits if false information materially
related to a claim was provided by the applicant.
NOTICE TO LOUISIANA APPLICANTS: Any person
who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a
crime and may be subject to fines and confinement in
prison.
NOTICE TO MARYLAND APPLICANTS: Any person
who knowingly and wilfully presents a false or
fraudulent claim for payment of a loss or benefit or who
knowingly and wilfully presents false information in an
application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
NOTICE TO NEW JERSEY APPLICANTS: Any person
who includes any false or misleading information on an
application for an insurance policy is subject to criminal
and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person
who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a
crime and may be subject to civil fines and criminal
penalties.
NOTICE TO NEW YORK APPLICANTS: Any person
who knowingly and with intent to defraud any insurance
company or other person files an application for
insurance or statement of claim containing any
materially false information, or conceals for the purpose
of misleading, information concerning any fact material
thereto, commits a fraudulent insurance act, which is a
crime, and shall also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the
claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with
intent to defraud or knowing that he is facilitating a
fraud against an insurer, submits an application or files
a claim containing a false or deceptive statement is
guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING:
Any person who knowingly, and with intent to injure,
defraud or deceive any insurer, makes any claim for the
proceeds of an insurance policy containing any false,
incomplete or misleading information is guilty of a
felony.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to
knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of
defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.
NOTICE TO WASHINGTON APPLICANTS: It is a crime
to knowingly provide false, incomplete, or misleading
information to an insurance company for the purposes
of defrauding the company. Penalties include
imprisonment, fines, and denial of insurance benefits.
NOTICE TO ALL OTHER APPLICANTS:
ANY PERSON WHO KNOWINGLY AND WITH INTENT
TO DEFRAUD ANY INSURANCE COMPANY OR
ANOTHER PERSON, FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM
CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS INFORMATION FOR
THE PURPOSE OF MISLEADING, COMMITS A
FRAUDULENT INSURANCE ACT, WHICH IS A CRIME
AND MAY SUBJECT SUCH PERSON TO CRIMINAL
AND CIVIL PENALTIES.
FRAUD WARNING STATEMENTS (REPRESENTATION
STATES ONLY – AK, AL, AZ, DE, FL, GA, HI, ID, KS,
Page 9 of 9
KY, ME, MT, NC, NH, NV, OR, PA, SD, VA, WV and
WY)
NOTICE TO FLORIDA APPLICANTS: Any person who
knowingly and with intent to injure, defraud or deceive
any insurer files a statement of claim or an application
containing any false, incomplete or misleading
information is guilty of a felony of the third degree.
NOTICE TO KENTUCKY APPLICANTS: Any person
who knowingly and with intent to defraud any insurance
company or other person files an application for
insurance containing any materially false information or
conceals, for the purpose of misleading, information
concerning any fact material thereto commits a
fraudulent insurance act, which is a crime.
NOTICE TO MAINE APPLICANTS: It is a crime to
knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of
defrauding the company. Penalties may include
imprisonment, fines or a denial of insurance benefits.
NOTICE TO OREGON APPLICANTS: Any person who
knowingly and with intent to defraud any insurance
company or another person, files an application for
insurance or statement of claim containing any
materially false information, or conceals information for
the purpose of misleading, commits a fraudulent
insurance act, which may be a crime and may subject
such person to criminal and civil penalties.
NOTICE TO PENNSYLVANIA APPLICANTS: Any
person who knowingly and with intent to defraud any
insurance company or other person files an application
for insurance or statement of claim containing any
materially false information or conceals for the purpose
of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a
crime and subjects such person to criminal and civil
penalties.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to
knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of
defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.
NOTICE TO WEST VIRGINIA APPLICANTS: Any
person who knowingly presents a false or fraudulent
claim for payment of a loss or benefit or knowingly
presents false information in an application for
insurance is guilty of a crime and may be subject to
fines and confinement in prison.
NOTICE TO ALL OTHER APPLICANTS:
ANY PERSON WHO KNOWINGLY AND WITH INTENT
TO DEFRAUD ANY INSURANCE COMPANY OR
ANOTHER PERSON, FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM
CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS INFORMATION FOR
THE PURPOSE OF MISLEADING, COMMITS A
FRAUDULENT INSURANCE ACT, WHICH IS A CRIME
AND MAY SUBJECT SUCH PERSON TO CRIMINAL
AND CIVIL PENALTIES.
14. DECLARATION
I declare that the information given above is, to the best of my knowledge and belief, true and complete and that I am
not aware of any circumstances that I have not disclosed to you which might influence your assessment of the risk.
I agree that, if you issue a Policy to us, this Application form and any additional information (oral and written) we have
provided to you, shall form the basis of and be incorporated into the Policy.
Name of signatory: _____________________________________________________________________________
Position in the company: ________________________________________________________________________
Signature: Date:
For and on behalf of: (Applicant’s Name)
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Application Trade Credit Insurance (Chubb)

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Completed 10 June 2021

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