Political Risk Insurance Quote For a whole turnover quote – please fill in a different form: Whole Turnover Quote Form For a single credit risk quote – please fill in a different form: Single Credit Risk Quote Form Phone Your Company Information Company Name * Country Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, the former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Sector Detailed Business Description Telephone Number * Email Address * Confirm Email Address * Name of Contact Person * Exposure To Be Insured Currency of Transaction USD GBP EUR JPY Size of Your Exposure Before Insurance Type of Transaction - Please Describe In Your Own Words Tenor of Exposure (please specify days, months, years) Please Describe the Assets if Insurance Involves Covering PRI Value of the Assets Name and Legal Status of the Entity Owning the Assets to Be Insured Address of the Entity Owning the Assets Period of Location in the Foreign Country (In Months) Please Add Any Other Comments Relevant to the Assets to Be Insured not Answered Above Name of the Main Obligor, If Any Address of the Main Obligor, If Applicable Major Shareholders and Ownership of the Main Obligor If Applicable, Any Other Obligor(s) Involved in the Transaction Explain the Involvement of the Other Obligor(s) and How Recourse to them Is Invoked in case of the Main Obligor's Default Are There Any Other Third Parties Involved (e.g. Offtakers, Suppliers, Collateral Agents)? Please Describe their Role and Provide their Addresses Any Other Comments Regarding the Counterparties Involved in the Transaction Previous Experience of the Applicant Relevant to the Risk(s) to be Insured Does the Applicant Have a Previous Experience of Working with the Obligor(s) and/or in the Country of Risk Yes No How Long Has the Applicant Had a Working Relationship With the Obligor(s) and Other Parties in the Transaction? Has the Applicant or their Affiliates Ever Experienced a Loss from Working with the Obligor(s) and/or in the Country of Risks? If Yes, Please Describe Is the Applicant Aware of Any Issues with the Obligor(s) or in the Country of Risk which May Give Rise to a Claim under the Policy? If Yes, Please Describe Please Provide Full Details of any Material Problems when Working with the Obligor(s) and/or in the Country of Risk Previously The Applicant represents that to the best of its knowledge and belief (Please check all that apply) No obligor(s) has defaulted on any senior obligations in the course of the last five years (if this is not the case, please provide details below) The obligor(s) have met their obligations within max of 90 days of due dates in the last five years (if not, please provide details below): Any repayment difficulties have not lead to a rescheduling of the debts of the obligor(s), in the last five years (if not, please provide details below): Repayment Difficulties If Any Type of Insurance Cover Sought Type of Insurance Sought Full comprehensive non-payment insurance Non-performance insurance Sovereign default cover Unfair calling of a guarantee by a beneficiary Political risk insurance (PRI) only: - Confiscation, Expropriation, Nationalisation, Deprivation (CEND) - Contract repudiation - Licence or other authorisation cancellation - Currency inconvertibility or non-transferability - Sanctions, export or import embargo - Forced divestiture - Forced abandonment for a period exceeding  year - Political violence - War and civil war - Non-honouring of an arbitration award Other - please describe Amount of Cover Requested by the Applicant Indemnity Percentage, X% of Exposure Period of Cover Requested (e.g. 12 Months Starting DD/MM/YY Until DD/MM/YY Inclusive) Please Describe Any Material Events That May Have Occurred Since the Start of the Transaction and the Reason for the Applicant's Interest to Use the Insurance Market to Reduce its Existing Exposure Please Provide Any Other Comments Relating to the Insurance Coverage Sought Supporting Documents for the Underlying Transaction (only jpg, pdf, txt files) Add Files Declaration The Applicant confirms that its statements in this Application are true and no material information has been withheld. The Applicant confirms that the existence of any policy issued will not be disclosed to the obligor(s) or any other third party other than our own professional advisors on a confidential basis or as required by law and except as may be permitted in accordance with the terms of any policy issued. The Applicant also confirms that it is aware that non-disclosure of any material information known to the insured may void the policy. The Authorized Officer of the Applicant agrees that all information in this Application will be treated confidentially by the Applicant. Signing of this Application does not bind the Applicant to purchase the requested insurance. The Applicant hereby appoints Political And Credit Risks Ltd as our broker of record for the placement of any policy of which this Proposal Form forms the basis.