Form EIB 92-79 EIB 92-79 Export-Import Bank of the United States Broker Registrat

OMB #3048-0009
Expiry Date 04/30/2007

EXPORT-IMPORT BANK OF THE UNITED STATES (EX-IM BANK)
BROKER REGISTRATION FORM
Insurance brokers and agents are eligible for commission payments under Ex-Im Bank export credit insurance policies if the broker or
agent is registered with Ex-Im Bank and is appointed as broker-of-record by the policyholder either by designation on an insurance policy
application or by separate letter.

Name of Brokerage_____________________________________________________
Contact:____________________________________Title:___________________________
Address:___________________________________ PO BOX:_______________________
City: ___________________State: ______________Zip:_________________________
Phone: (_____)________________ Fax: (_____)______________ E-Mail:______________
Tax ID #:_____________________ DUNS #:_________________ No. of Employees:______
Indicate (Not Required) if owned by a woman or an ethnic minority, describe _____________
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 the Ex-Im Bank Internet Website and unbrokered applicants are
referred to the list. Please indicate here if you DO NOT wish your name released.
1. A Registration Fee of $35.00 is required
2. You are required to review, understand and sign the attached “Standards of Service”.
3. Attach a copy of a current, valid insurance brokerage license indicating issuance and/or expiry date(s).
4. Forward the attached “Authorization for Automated Deposits” form.
The Broker (it) CERTIFIES and ACKNOWLEDGES to the Ex-Im Bank (the Bank) that:
1. a) neither it nor its principals has been within the past 3 years:
1) debarred, suspended or declared ineligible from participating in or voluntarily excluded from participation in a
Covered Transaction or
2) formally proposed for debarment, with a final determination still pending;
3) indicted, convicted or had a civil judgement rendered against them for any of the offenses listed in the
Government Wide Nonprocurement Debarment and Suspension Regulations; Common Rule which defines
Covered Transaction.
4) It certifies that it is not delinquent on any amounts due and owing to the U.S. Government, its agencies or
instrumentalities as of the date of this application. OR
b) It has received a written statement of exception from the Bank and attached it to this certification, permitting
participation in the transaction despite an inability to make certifications 1 through 4.
It further certifies that it has not and will not knowingly enter into any agreements in connection with the
transaction with any individual or entity that has been subject to 1, 2 or 3 above.

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2. it will complete and submit Form-LLL, Disclosure Form to Report Lobbying if, to the best of its knowledge and belief,
any funds have been paid or will be paid to any person in connection with this application for influencing or attempting to
influence:
a) an officer or employee of any U.S. Government agency, or
b) a Member of Congress or a Member’s employee, or
c) an officer or employee of Congress.
3. corrupt payments made in connection with Bank supported transactions may be a violation of the Foreign Corrupt
Practices Act of 1977 (15 USC 78dd-1, et. seq.) which provides for civil and criminal penalties against individuals who
directly or indirectly make or facilitate corrupt payments to foreign officials to obtain or keep business.
4. a) the information being requested is done so under authority of the Export-Import Bank Act of 1945 (12 USC 635
et.seq.);
b) providing the information is mandatory. Failure to do so may result in the Bank being unable to
determine eligibility for the Insurance Program. The information provided will be reviewed to determine if the
broker meets the Bank’s legislative requirements under the program
c) the Bank may not require the information and applicants are not required to respond unless a currently valid OMB
control number is displayed on this form (see upper right of each page);
d) the information provided will be held confidential subject to the Freedom of Information Act (5 USC
552) and the Privacy Act of 1974 (5 USC 552a), except as required to be disclosed under applicable laws;
e) the Bank shall have a right to transfer to another U.S. Government authority any financial records included in this
certification or other correspondence as necessary to process, service, foreclose or collect on an insured debt.
No other transfer of records to private parties or another U.S. Government authority will be authorized except as permitted
under the Right of Financial Privacy Act of 1978 (12 USC 3401).
f) the public burden reporting for this collection of information is estimated to average ½ hour per response, including
reviewing instructions, searching data sources, gathering information, completing, and reviewing the application.
Send comments regarding the burden estimate, including suggestions for reducing it, to Office of Management and
Budget, Paperwork Reduction Project, Washington, D.C. 20503.
5. the representations made and the facts stated by it in these certifications and its attachments are true, to the best
of its knowledge and belief, and it has not misrepresented or omitted any material facts. It further
understands that these certifications are subject to the penalties for fraud against the U.S. Government (18 USC
1001).
Signature: ___________________________
Title: _______________________

Print Name:____________________________
Date: ______________

Send this application to Attn: Business Development , Ex-Im Bank,
811 Vermont Avenue, NW, Washington, D.C. 20571 or an Ex-Im Regional Office.
The Ex-Im Bank website is http://www.exim.gov

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INSURANCE BROKERS
STANDARDS OF SERVICE
1. To act in a professional, reasonable, prudent and forthright manner in all dealings with your client and Ex-Im
Bank.
2. To make certain that your clients understand that you are neither an Official Representative.
3. To stay knowledgeable about not only Ex-Im Bank export credit insurance but alternatives, including other ExIm Bank programs, other U.S. government programs, and private sector products as well, in order to provide the
best options to your clients.
4. To educate your clients about Ex-Im Bank's Insurance Program and policies, its' benefits and proper usage.
5. To serve as your clients' primary contact for any questions concerning the policies and the servicing of a policy.
6. To review all applications and issuances of policies, actions under policies, renewals of policies and credit limits,
and claims, for timeliness, completeness, accuracy and reasonableness.
7. To review correspondence from Ex-Im Bank with your clients, including quotes and credit limits, to assist them
in understanding the coverage and their responsibilities.
8. To assist your clients to comply with the Agreements of the Insured including shipment reports, premium
payment and reports of overdue accounts, and to advise Ex-Im Bank of any potential claims.
9. To report policy cancellations and submit a premium reconciliation to Ex-Im Bank.
I have read the above standards, agree that they are reasonable, and will comply with these standards.
I understand and agree that substantial failure by me to comply with these standards could result in withdrawal from
the list of registered insurance brokers published by Ex-Im Bank and cancellation of eligibility for commission
payments under Ex-Im Bank export credit insurance policies.

________________
Name of Brokerage

________________________
Signature of Broker

____________________
Date

______________________________
Print Name

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EXPORT-IMPORT BANK OF THE UNITED STATES
AUTHORIZATION FOR AUTOMATED DEPOSITS
(ACH CREDITS)

I hereby authorize the Export-Import Bank of the United States hereinafter called Ex-Im Bank, to initiate credit entries to
my [ ] CHECKING [ ] SAVINGS account (check one) indicated below and the depository named below, hereinafter
called DEPOSITORY, to credit the same to such account.
DEPOSITORY NAME ________________________________
BRANCH _________________________________
CITY _____________ STATE_____________ ZIP___________________

TRANSIT/ABA NUMBER:

□□□□ □□□□ □
-

-

ACCOUNT NUMBER: ___________________________________
This authority is to remain in full force and effect until Ex-Im Bank has received written notification from me of its
termination in such time and in such manner as to afford Ex-Im Bank a reasonable opportunity to act on it.
BROKER NAME ____________________________________________________
(please print)
BROKER NO._______________________________________
SIGNATURE_________________________ DATE ____________________
PLEASE ATTACH A VOIDED CHECK FOR THE ACCOUNT NAMED ABOVE
-----------------------------------------------------------------------------------------------------FOR EX-IM BANK USE ONLY
DATE RECEIVED

PROCESSED BY
Return to: Export-Import Bank of the United States
Director - Broker Relations
811 Vermont Avenue, N.W.
Washington, DC 20571

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EXPORT-IMPORT BANK OF THE UNITED STATES (EX-IM BANK)
BROKER COMMISSION SCHEDULE
FOR EXPORT CREDIT INSURANCE POLICIES
Effective: April 1, 2006
BROKER ELIGIBILITY
Insurance brokers and agents are eligible for commission payments under Ex-Im Bank export credit insurance policies if the broker or
agent is registered with Ex-Im Bank and is appointed as broker-of-record by the policyholder. The policyholder reserves the right to
appoint, delete or change the broker of record at any time. Brokers of record are entitled to any commissions due on premiums paid prior
to a change in the broker of record.

COMMISSION RATES
Commission rates paid by Ex-Im Bank are based on the type of policyholder to which the policy is issued, as shown in the chart below:

Type of Policyholder Commission Rate (percentage of premium)
Financial Institutions 8%
Exporters

Multi-Buyer Policyholders: Ex-Im Bank Small Business* 40%
Multi-Buyer Policyholders: All others 15%
Short Term Single-Buyer Policyholders: SBA Small Business15%
Short Term Single-Buyer Policyholders: All others 10%
Medium Term Single-Buyer: 10%
Lessors

(policyholder is either a financial institution or an exporter)
Operating Lease Policy 20%
Financing Lease Policy 10%
* Ex-Im Bank Small Business is defined as an exporter that meets applicable SBA small business criteria and having annual
export credit sales of $5 million and less.

COMMISSION PAYMENTS
- The full amount of all premiums are due at the appropriate lockbox on or before the date specified in the policy.
- Insurance brokers should not remit premiums "net" of commission.
- Commission payments will be made monthly.
- No commission payments will be made on advance premium.

BROKER CHANGES ON EXISTING POLICIES
Ex-Im Bank policyholders may appoint or change their insurance broker at any time. Insurance brokers appointed after a policy is issued
will be recognized on the first day of the next month after the receipt of the policyholder's written notice appointing an insurance broker of
record. Acknowledgment by Ex-Im Bank of a policyholder's appointed insurance broker is made by means of a policy endorsement.
Insurance brokers acknowledged by Ex-Im Bank are eligible for commissions with respect to transactions occurring after the effective
date of the endorsement.

WHO TO CONTACT: For additional information, please contact Ms. Judith Rivera, Director, Broker Relations at 202-5653417 or Judith.rivera@exim.gov , 811 Vermont Avenue, N.W., Washington, D.C. 20571
Or: an Ex-Im Bank Regional Office: NORTHEAST 212.809.2650; MIDWEST 312.353.8081; SOUTHEAST 305.526.7436;
SOUTHWEST 281.721.0465; WEST: Long Beach 562.980.4580, San Diego 619.557.7091, San Francisco 415.705.2285 General
Inquiries: TEL. 202.565.EXIM (3946) OR 1.800.565.EXIM (3946); FAX 202.565.3723; www.exim.gov; info@exim.gov

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