Portfolio Of Credit Risks Quote For a single credit risk quote – please fill in a different form: Single Credit Quote Form For a political risk quote – please fill in a different form: Political Risk Quote Form Order Number Your Company Information Registered Company Name * Address * 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 Company registration number VAT number Sector Detailed Business Description Telephone Number * Email Address * Confirm Email Address * Name of Contact Person * Annual Sales Projection Projected Annual Turnover - Domestic Projected Annual Turnover - Export Currency AED - UAE Dirham AFN - Afghani ALL - Lek AMD - Armenian Dram ANG - Netherlands Antillean Guilder AOA - Kwanza ARS - Argentine Peso AUD - Australian Dollar AWG - Aruban Florin AZN - Azerbaijanian Manat BAM - Convertible Mark BBD - Barbados Dollar BDT - Taka BGN - Bulgarian Lev BHD - Bahraini Dinar BIF - Burundi Franc BMD - Bermudian Dollar BND - Brunei Dollar BOB - Boliviano BOV - Mvdol BRL - Brazilian Real BSD - Bahamian Dollar BTN - Ngultrum BWP - Pula BYN - Belarusian Ruble BZD - Belize Dollar CAD - Canadian Dollar CDF - Congolese Franc CHE - WIR Euro CHF - Swiss Franc CHW - WIR Franc CLF - Unidad de Fomento CLP - Chilean Peso CNY - Yuan Renminbi COP - Colombian Peso COU - Unidad de Valor Real CRC - Costa Rican Colon CUC - Peso Convertible CUP - Cuban Peso CVE - Cabo Verde Escudo CZK - Czech Koruna DJF - Djibouti Franc DKK - Danish Krone DOP - Dominican Peso DZD - Algerian Dinar EGP - Egyptian Pound ERN - Nakfa ETB - Ethiopian Birr EUR - Euro FJD - Fiji Dollar FKP - Falkland Islands Pound GBP - Pound Sterling GEL - Lari GHS - Ghana Cedi GIP - Gibraltar Pound GMD - Dalasi GNF - Guinea Franc GTQ - Quetzal GYD - Guyana Dollar HKD - Hong Kong Dollar HNL - Lempira HRK - Kuna HTG - Gourde HUF - Forint IDR - Rupiah ILS - New Israeli Sheqel INR - Indian Rupee IQD - Iraqi Dinar IRR - Iranian Rial ISK - Iceland Krona JMD - Jamaican Dollar JOD - Jordanian Dinar JPY - Yen KES - Kenyan Shilling KGS - Som KHR - Riel KMF - Comoro Franc KPW - North Korean Won KRW - Won KWD - Kuwaiti Dinar KYD - Cayman Islands Dollar KZT - Tenge LAK - Kip LBP - Lebanese Pound LKR - Sri Lanka Rupee LRD - Liberian Dollar LSL - Loti LYD - Libyan Dinar MAD - Moroccan Dirham MDL - Moldovan Leu MGA - Malagasy Ariary MKD - Denar MMK - Kyat MNT - Tugrik MOP - Pataca MRO - Ouguiya MUR - Mauritius Rupee MVR - Rufiyaa MWK - Malawi Kwacha MXN - Mexican Peso MXV - Mexican Unidad de Inversion (UDI) MYR - Malaysian Ringgit MZN - Mozambique Metical NAD - Namibia Dollar NGN - Naira NIO - Cordoba Oro NOK - Norwegian Krone NPR - Nepalese Rupee NZD - New Zealand Dollar OMR - Rial Omani PAB - Balboa PEN - Sol PGK - Kina PHP - Philippine Peso PKR - Pakistan Rupee PLN - Zloty PYG - Guarani QAR - Qatari Rial RON - Romanian Leu RSD - Serbian Dinar RUB - Russian Ruble RWF - Rwanda Franc SAR - Saudi Riyal SBD - Solomon Islands Dollar SCR - Seychelles Rupee SDG - Sudanese Pound SEK - Swedish Krona SGD - Singapore Dollar SHP - Saint Helena Pound SLL - Leone SOS - Somali Shilling SRD - Surinam Dollar SSP - South Sudanese Pound STD - Dobra SVC - El Salvador Colon SYP - Syrian Pound SZL - Lilangeni THB - Baht TJS - Somoni TMT - Turkmenistan New Manat TND - Tunisian Dinar TOP - Pa’anga TRY - Turkish Lira TTD - Trinidad and Tobago Dollar TWD - New Taiwan Dollar TZS - Tanzanian Shilling UAH - Hryvnia UGX - Uganda Shilling USD - US Dollar UYI - Uruguay Peso en Unidades Indexadas (URUIURUI) UYU - Peso Uruguayo UZS - Uzbekistan Sum VEF - Bolívar VND - Dong VUV - Vatu WST - Tala XAF - CFA Franc BEAC XCD - East Caribbean Dollar XDR - SDR (Special Drawing Right) XOF - CFA Franc BCEAO XPF - CFP Franc XSU - Sucre YER - Yemeni Rial ZAR - Rand ZMW - Zambian Kwacha ZWL - Zimbabwe Dollar Your Credit Control Function Does your credit control operate from your mailing address? Yes No What are your normal payment terms? 7 days from date of invoice 30 days from date of invoice 60 days from date of invoice 90 days from date of invoice 120 days from date of invoice 7 days end of month from date of invoice 30 days end of month from date of invoice 60 days end of month from date of invoice 90 days end of month from date of invoice 120 days end of month from date of invoice Greater than 120 days Are your terms and due dates shown on your invoices? Yes No Are you always a contractual principal, i.e. a party legally entitled to take recovery action? Yes No How many days after the goods are delivered/services rendered do you issue an invoice? 0-7 days 8-14 days Other How many days after due date do you chase the customer? Before 1 day 2-7 days 8-14 days 15-30 days Other How many days after the due date do you put an account on stop? 0-7 days 8-14 days 15-30 days 31-60 days Other When do you start legal action? 0-7 days 8-14 days 15-30 days 31-60 days Other Please note that you are required, where applicable, to take all practicable measures to exercise your Retention of Title clause in every case. Do you have an all-monies retention of title clause in your terms and conditions of sale? Yes No Do you incorporate those conditions into every contract of sale with your customer? Yes No If you have answered yes to this question you will only be insured for the risk of non-payment of debts where those conditions are incorporated into your sales contract. Your Trading History Insert total annual turnover and other metrics for the last three complete financial years, excluding cash sales, sales to associated and subsidiary companies, UK government and local authorities, sales made on letters of credit confirmed by a bank in the UK and Value Added Tax 2017 2016 2015 Your Total Sales 2017 Total Sales 2016 Total Sales 2015 Total Sales Total Number of Bad Debt Cases 2017 Number of Bad Debt Cases 2016 Number of Bad Debt Cases 2015 Number of Bad Debt Cases Total Value of Bad Debts 2017 Value of Bad Debts 2016 Value of Bad Debts 2015 Value of Bad Debts Value of Largest Single Bad Debt 2017 Value Largest Bad Debt 2016 Value Largest Bad Debt 2015 Value Largest Bad Debt Debtor Analysis Current amounts owing by your debtors listed by the value currently outstanding Debtor range - number of debtors Over 500,000 250,001-500,000 100,001-250,000 50,001-100,000 25,001-50,000 Combined value of debt by these debtors Over 500,000 250,001-500,000 100,001-250,000 50,001-100,000 25,001-50,000 Debtor range - number of debtors 10,001-25,000 5,001-10,000 2,501-5,000 1,001-2,500 up to 1,000 TOTALS - Number of Debtors Combined value of debt by these debtors 10,001-25,000 5,001-10,000 2,501-5,000 1,001-2,500 up to 1,000 TOTALS - Combined Value of Debt Overdue Accounts The value outstanding by the number of days overdue past the due date of payment at the current moment 1-30 days overdue 31-60 days overdue 61-90 days overdue >90 days overdue Key Customers List your key customers and the credit limit required Name of customer Name of customer Name of customer Name of customer Name of customer Address Address Address Address Address Ultimate Beneficial Owner(s) - UBO We have one or more Ultimate Beneficial Owner(s) with an Interest in us of 25% or more. Details below Why do we require details of the company’s ultimate beneficial owners? Due to the regulations on the prevention of the use of the financial system for laundering of money, the financing of terrorism and the obligation to adhere to sanction regulations, financial institutions are obliged to comply with national and international rules and regulations. As an insurance broker, there is a regulatory requirement for us to identify the persons with whom we have a ‘relation’. First name and surname First name and surname First name and surname Address of UBO Address of UBO Address of UBO Date of Birth of UBO Date of Birth of UBO Date of Birth of UBO Ownership % Ownership % Ownership % General Information Number of years trading Do you currently have credit insurance? Yes No Have you ever been refused a credit insurance policy or been refused the renewal of one? Yes No How did you hear about us? Recommendation Search Engine Trade Association Personal Meeting Other Please specify 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.