Form OPIC 247 OPIC 247 OPIC 247-New-Short Form- Application for Political Risk

	OPIC-247
Short-Form Application for Political Risk Insurance (To be used only in conjunction with a completed application for OPIC financing) Section I: Investor and Project Information Section II: Signature Overseas Private Investment Corporation An Agency of the United States Government 1100 New York Avenue, N.W. Washington, DC 20527 www.opic.gov Insurance Department Tel.: (202) 336-8400 Fax: (202) 408-5142
NOTICE: This form requests from potential OPIC clients information that is required by OPIC’s governing legislation - the Foreign Assistance Act of 1961, Title IV, as amended (“FAA”) - to determine whether a project and its sponsor(s) meet eligibility criteria for OPIC political risk insurance. Complete responses to the questions on this form are required to apply for OPIC insurance benefits under the FAA. Client information contained in this questionnaire will be deemed designated as privileged or confidential in accordance with OPIC’s Freedom of Information Act (FOIA) regulations (22 CFR part 706) and will be treated as confidential to the extent permitted under FOIA.
Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to Forms Manager, OCFO – Security and Administrative Services, Overseas Private Investment Corporation, 1100 New York Avenue, N.W., Washington, D.C. 20527; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

Application for Political Risk Insurance – Section I

The Overseas Private Investment Corporation (OPIC) requests information on this application to determine whether the Investor and the project meet eligibility requirements for insurance, specifically with regard to underwriting criteria and legislative and regulatory compliance. Information provided to OPIC must be accurate as of the date an OPIC contract is issued. Responses to questions that call for estimates or projections should take the form of good faith statements made to the best of the Investor’s knowledge and belief, after due inquiry. Misrepresentations or failure to disclose relevant information may result in the cancellation of insurance. Neither issuance of a registration letter nor acknowledgment of receipt of this application implies that the investment is eligible for political risk insurance or that a contract will be issued.

INSTRUCTIONS:

Please contact an insurance officer at (202) 336-8400 if you have any questions about this application.

1. All applicants must fill out a complete application which is composed of Sections I and sign Section II.

2. All applicants must provide the certifications requested in Parts 5 and 6 of Section I.

3. If you use an attachment to answer any of the questions in this application, please write “see Attachment” in the appropriate answer block and indicate the corresponding question number on your attachment.

3. All applicants applying for OPIC insurance must sign this application in Section II. If an Investor is applying for OPIC insurance on behalf of other eligible Investors, OPIC also will require the ultimate beneficiary Investors to sign this application.

3. When completed, please submit:^

a. Completed application (Sections I-II), and

b. One (1) copy of all attachments and supporting documentation to:

Applications Officer – Insurance Department

Overseas Private Investment Corporation

1100 New York Avenue, N.W.

Washington, DC 20527

Section I - Investor and Project Information

Part 1: Investor Information (Investor to be Insured by OPIC)

1.

Name of Investor:

                                                  

OPIC Insurance Registration Number:

                DUNS #:                

(See OPIC registration letter for assigned number.)

Address:

                                                                                

City:

                    

State:

               

Zip/Postal Code:

               

Country:

                    

Telephone:

               

Fax:

               

E-Mail:

                    

Website:

               

Occupation (if individual):

               

Location of registration/incorporation (if entity):

               

2.

Type of Investor (check one investor type only)



Entity Organized Under U.S. Law

a.

Is more than 50% of both the total equity interest and each class of equity interests issued by the Investor and outstanding on the date hereof beneficially owned by U.S. citizens?* (If No, please contact OPIC before proceeding.)

Yes

 No

b.

Is this entity a minority-owned business?

 Yes

 No

c.

Is this entity a women-owned business?

 Yes

 No



Individual Investor

a.

Is the Investor a citizen of the United States? (If No, please contact OPIC before proceeding.)

 Yes

 No



Entity Organized Outside of the United States

a.

If organized other than as a corporation, is 100% of both the total equity interest and each class of shares or equity interests issued by the Investor and outstanding beneficially owned by U.S. citizens? (If No, please contact OPIC before proceeding.)

 Yes

 No

b.

If organized as a corporation, is 95% or more of both the total equity interest and each class of shares or equity interests issued by the Investor and outstanding beneficially owned U.S. citizens? (If No, please contact OPIC before proceeding.)

 Yes

 No



Non-Profit/Non-Governmental Organization organized under U.S. Law

a.

Is more than 50% of the Board of Directors composed of U.S. citizens?

 Yes

 No



Non-Profit/Non-Governmental Organization organized outside of the U.S.

a.

Is 100% of the Board of Directors composed of U.S. citizens?

 Yes

 No

3.

Name of Person OPIC should contact for information:

                              

Title:

                    

Company:

                              

Address:

                                                  

City:

                    

State:

               

Zip/Postal Code:

               

Country:

                    

Telephone:

               

Fax:

               

E-Mail:

                    

*

OPIC deems a corporation organized under the laws of the U.S. or its states or territories to be beneficially owned by U.S. citizens if more than 50 percent of each class of its issued and outstanding stock is owned by U.S. citizens either directly or beneficially.

4.	How did you learn about OPIC and its services?
			conference		OPIC Web site		other government agency (SBA, TDA, EX-IM)
			insurance broker		former OPIC clients		other (please explain)	          
Part 2: Private Political Risk Insurance
	OPIC strongly encourages Investors to consider carefully the availability of private political risk insurance for their investments abroad. OPIC only offers insurance to Investors who, having investigated the possibility of obtaining insurance from private political risk insurers, decide to pursue OPIC insurance because private insurance is not available on terms sufficient to make the investment viable for the Investor, or because of specific benefits OPIC participation will bring to the investment.
5.	Have you sought political risk insurance from the U.S. private political risk insurance market for the project?*								 Yes	 No
6.	If private political risk insurance is available, is it in the amount necessary and on terms sufficient for the project’s viability?								 Yes	 No
	If Yes, please explain why political risk insurance is being sought from OPIC. If No, please explain.
Part 3: Project Information
7.	Project Description
a.	Briefly describe the project and investment structure.
b.	Please attach a copy of information memoranda, business plans, investment structure diagram or other descriptions of the project that would be helpful to OPIC’s understanding of the project. Also provide copies of any project documentation such as company charter, joint venture documents, loan agreements, technical assistance agreements, management service agreements, lease agreements, loan guaranties, licenses or agreements with the host government, etc. All documentation must be in English.
c.	If entering into a contract to provide goods/services to a foreign government, please indicate total amount, date contract was/will be signed, and approximate date work will commence. Please attach a copy of the contract as well.

8.

Please specify whether this project is:



an expansion of an existing enterprise



a new (greenfield) enterprise



a privatization of a state-owned company



other (please explain)

          

9.

Where is the project located? (If in a remote location, please include GPS coordinates or attach a map showing the location.)

10.

Name of the entity (the “Foreign Enterprise”) in the host country into which the investment will be made:

Foreign Enterprise:

                                                  

Address:

                                                  

City:

               

Postal Code:

               

Country:

               

Telephone:

               

Fax:

               

E-Mail:

               

11.

Government Involvement

a.

Describe any host government involvement in the project such as any contracts, concession, or licenses from the government, any planned government purchasing or supplying, or any form of joint venture with the government.

b.

If entering into a contract to provide goods/services to a foreign government, give the name and address of the department or agency involved. Briefly describe any previous experience the Investor has had with this foreign government.

12.

Please identify and describe briefly any current or past disputes with respect to this project that involve any agency or instrumentality of the host government. Include all disputes that involved or currently involve the Investor, the Foreign Enterprise, or any participants in the project.

Part 4: Investment to be Insured by OPIC

13.

Type of Investment to be Insured (Check all that apply)

Amount



Equity

$           



Leases

$           



Loans or Loan Guaranties

$           



Technical Assistance or Management Agreements

$           



Performance Guaranty/Advance Payment Guaranty/Other Guaranty/Contract Disputes

$           



Other (please explain)

$           

14.

Type of Coverage Sought (Check all that apply)



Expropriation



Political Violence for Assets



Non-Honoring of a Sovereign Guarantee*



Inconvertibility



Political Violence for Business Income



Wrongful Calling of a Guaranty (Bid bonds, advance payment, etc.)

(If seeking coverage for wrongful calling of a guaranty, please provide draft/final copy of each of the guaranties you wish to insure).

15.

Term of OPIC Contract:

      years

(OPIC can offer a minimum term of 3 years and a maximum term of 20 years)

16.

Investment Schedule

Date

Amount

a.

Initial Investment

          

$           

b.

Subsequent Investment(s)

          

$           

          

$           

          

$           

c.

Expected date that commercial operations will begin:

          

* Please consult with OPIC regarding specific eligibility requirements for this coverage before proceeding.

Section II – Signature
	Each Investor must sign this application. The signature applies to Section I.
	Applicant (Investor):	          	Applicant (Investor):	          
	By:		By:
	Name & Title (print):	          	Name & Title (print):	          
	Date:	     	Date:	     
By signing this form, the Investor(s) hereby represents and warrants that (a) this form is identical in all material and substantive respects to the form sent to the Investor by OPIC and (b) that the Investor understands that OPIC shall regard the Investor’s answers to the questions on this form to be answers to the questions as asked on the form sent to the Investor by OPIC.

 Signed applications may be submitted by fax to (202) 408-5142. Alternatively, signed electronic applications (for example in Adobe PDF or other readable formats) may be submitted by electronic mail to applyins@opic.gov. Supporting documentation may be submitted by fax to (202) 408-5142 or by electronic mail to applyins@opic.gov.