Fillable Export-Import Bank of the United States (EXIM) COMMISSIONED (Export-Import Bank of the United States)

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Export-Import Bank of the United States (EXIM) COMMISSIONED (Export-Import Bank of the United States)

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The Export-Import Bank of the United States (EXIM) COMMISSIONED (Export-Import Bank of the United States) form is 4 pages long and contains:

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U.S.A. forms for Export-Import Bank of the United States

BROWSE EXPORT-IMPORT BANK OF THE UNITED STATES (DC) FORMS

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OMB
Expires 11/30/2021
EIB 92-79
Revised 10/2017
0123!!!45!"!
Export-Import
Bank
of the
United
States (EXIM)
COMMISSIONED BROKER APPLICATION FORM
Subject!to!compliance!with!the!terms!and!conditions!of!this!Application!and!the!attached!Standards!of!Professional!Conduct!
and!Service,!an!insurance!broker!may!become!registered!with!EXIM!and!eligible!for!commission!payments!under!EXIM!
export!credit!insurance!policies!if!the!broker!is!appointed!as!broker-of-record!by!the!policyholder!either!by!designation!on!
an!insurance!policy!application!or!by!separate!letter.!The!commission!payments!shall!be!based!on!EXIM’s!“Broker!
Commission!Schedule”!in!effect!at!the!time!of!shipment!in!the!brokered!transaction.!
Name!of!Brokerage:!!____________________________________________________________________________________!!
Contact:!! __________________________________________!Title:!!______________________________________________!!
Address:!!__________________________________________________________!PO!Box:!! ___________________________!!
City:!!______________________________________________!State:!!_______________________!!Zip:!! _________________!!
Phone:!(_____)! _______________! Fax:!(_____)!! _________________!!Email:!!_ ____________________________________!!
Tax!ID#:!!__________________________!!DUNS!#:! _________________________!!No.!of!Employees:!! __________________!!
Other!lines!of!brokered!Insurance:!! ________________________________________________________________________! !
_____________________________________________________________________________________________________!!
Do!you!have!other!offices!you!wish!to!register!(to!be!eligible!for!commissions)?!_____!No!!!!_____!Yes!
If!“Yes”,!please!list!firm’s!name,!address,!telephone!number,!fax!number!and!contact!person!on!a!separate!sheet.!A!list!
of!registered!insurance!brokers!is!available!on!EXIM’s!website, and applicants seeking a broker!are!referred!to!the!list.!
#$$%&'#(&)*+,-./&,-0-*(1+#*2+&*1(,/'(&)*1+
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+/
F;;1:B!a copy of the Declarations page from your :7CC3@;!=C453DD?4@1>!>?18?>?;K!?@D7C1@:3!policyM
./ 6?2@!1@E!C3;7C@!;B3!1;;1:B3E!PF7;B4C?]1;?4@!54C!F7;4<1;3E!X3=4D?;DQ!54C<M
^/ 678<?;!1!E3D:C?=;?4@!45!K47C!87D?@3DD!4=3C1;?4@DI!AB?:B!DB47>E!?@:>7E3!1;!1!<?@?<7<S!)?/!C3>3H1@;!81:J2C47@E!1@E
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=C4<4;3!"XIM!=C42C1<D!;4!ZM6M!3L=4C;3CD_!1@E!)?H/!for any other individuals with your firm who are licensed
insurance brokers and will be broking EXIM products, provide 1!>?D;!45!@1<3D!45!1>>!such ?@E?H?E71>D!1@E!;B3
6;1;3D!?@!AB?:B!;B3K!1C3!>?:3@D3EM
'-,(&3&'#(&)*1+#*2+*)(&'-1+
NB3!$C4J3C!)?;/!'-,(&3&-1+456789+#':*);%-2<-1!to EXIM!;B3!54>>4A?@2S!
1.
Debarment,+Suspension+and+Delinquency.!(a)!Neither!it!nor!its!principals!has!been!within!the!past!3!years!(i)! debarred,
suspended!or!declared!ineligible!from!participating!in!or!voluntarily!excluded!from!participation!in!a!“Covered!Transaction”
defined! in! the! Government! wide! Debarment! and! Suspension! (Nonprocurement)! regulations! and!the!Export
Import!Bank of!the!United!States!Debarment!and!Suspension!(Nonprocurement)!regulations.;!!(ii)!!formally!proposed!for
debarment, with a final determination still pending; (iii) or indicted, convicted or had a civil judgment rendered against
it!for!any!of!the offenses! listed! in! the! Government! wide! Debarment! and! Suspension! (Nonprocurement)!regulations;!and
b) Neither!it!nor!its!principals!is!delinquent!on!any!amounts!due!and!owing!to!the!U.S.!Government,!its
agencies!or!instrumentalities!as!of!the!date!of!this!application;! and
c) In!connection!with!a!transaction,!it!has!not!and!will!not!knowingly!enter!into!any!agreements!or!affili ations
with!any!individual!or!entity!to!whom!items!(a)!o r!(b)!above!apply;!or
d) It!has!received!a!written!statement!of!exception!from!EXIM!and!attached!it!to!this!certification,
permitting!participation!in!the!transaction!despite!an!inability!to!make!certifications!(a)(i)1 (iii),!(b)!and!(c).
Please indicate here if you DO NOT wish to have your name released.
OMB
Expires 11/30/2021
EIB 92-79
Revised 10/2017
0123!J!45!"!
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"XIM!83?@2!7@18>3!;4!E3;3C<?@3!3>?2?8?>?;K!;4!83!1!C32?D;3C3E!8C4J3C!54C!"XIMOD!#@D7C1@:3!0C42C1<M!NB3 ?@54C<1;?4@
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EXIM!<1K!@4;!C3a7?C3!;B3!?@54C<1;?4@!C3a73D;3EI!1@E!1==>?:1@;D!1C3!@4;!C3a7?C3E!;4!C3D=4@EI!7@>3DD!1!:7CC3@;>K H1>?E
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5. '85LE6=5@E4FE@I+456+2ECHF8CB9=+*8@EH=M!!EXIM will endeavor to restrict the disclosure of all information provided in this
form to the fullest extent permissible under federal information disclosure laws including the Freedom of Information Act
(5 U.S.C. 552), the Privacy Act of 1974 (5 U.S.C. 552a), or under any other law or court
order.!!"XIM!DB1>>!B1H3!1!C?2B;!;4!;C1@D53C!;4!1@4;B3C!ZM6M!`4H3C@<3@;!17;B4C?;K!1@K!5?@1@:?1> C3:4CED
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OMB
Expires 11/30/2021
EIB 92-79
Revised 10/2017
0123!Z!45!"!
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OMB
Expires 11/30/2021
EIB 92-79
Revised 10/2017
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OMB
Expires 11/30/2021
EIB 92-79
Revised 10/2017
0123!"!45!"!
Export-Import
Bank
of the
United
States
BROKER COMMISSION SCHEDULE
FOR EXPORT CREDIT INSURANCE POLICIES
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**If the exporter is SBA Small Business but not EXIM Small Business, and is the beneficiary of an SBA or EXIM Working
Capital Loan Guaranty, the commission is 20%
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=4>?:K!3@E4CD3<3@;M!#@D7C1@:3!8C4J3CD!1:J@4A>3E23E!8K!"XIM!1C3!3>?2?8>3!54C!:4<<?DD?4@D!A?;B!C3D=3:;!;4!;C1@D1:;?4@D!
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;M8+(8+'85@4H@S!!W4C!1EE?;?4@1>!?@54C<1;?4@I!contact EXIM using the contact information below and ask for Broker Relations.
<=5=94F+&5GBE9E=CP+N"bM!'*'M^f^M"q#d!)+&.f/!Uc!-Me**M^f^M"q#d!)+&.f/_!WFq!'*'M^f^M+('+_!AAAM3L?<M24H_!info@exim.gov!
Paperwork Reduction Act Statement: We estimate that it will take you about 1/4 hour 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# 3048-0024; Washington, D.C. 20503.
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Export-Import Bank of the United States (EXIM) COMMISSIONED (Export-Import Bank of the United States)

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Completed 10 August 2020

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