Form EIB 92-64 EIB 92-64 EIB 92-64, Application for Exporter Short Term Single Bu

APPLICATION FOR EXPORTER SHORT-TERM,
SINGLE-BUYER INSURANCE

OMB No. 3048-0018
PENDING 2019

This application is to be completed by an Exporter (or a Broker acting on its behalf) in order to obtain a short-term
insurance policy covering sales to a single foreign Buyer. Repayment terms can be up to 360 days.
An online version of this application is available on EXIM’s web site. EXIM encourages customers to apply on line, as
it will facilitate our review and allow customers a faster response time. Additional information on how to apply for
EXIM insurance can be found on EXIM’s web www.exim.gov IMPORTANT: The Guarantor, Buyer and End User must
be foreign entities in countries for which EXIM is able to provide support, see EXIM's Country Limitation Schedule.
Send this completed application to EXIM, 811 Vermont Ave., NW, Washington, D.C. 20571. EXIM will also accept
Emailed PDF and faxed applications. EXIM will not require the originals of these applications to be mailed. The
application must be PDF scans of original application and all required documents. (Fax number 202.565.3380, Email
exim.applications@exim.gov)
APPLICATION FORM
Under corporate ownership, provide name of ultimate parent company, if there is a corporate owner. For
number of employees and sales volume, aggregate the information for the company and all its affiliates1,
including corporate owners and subsidiaries.
Applicant/Exporter Legal Name:
DUNS#
Tradestyle:
Business Address:
City:
State:
Zip + 4:
Country:
If there is Corporate Ownership of Applicant please state:
Does the Applicant have any affiliates: Yes No Applicants Primary Industry NAICS2:
Total Number of Employees (for Applicant and any affiliated companies):
Annual Sales Volume (for applicant and any affiliated companies):
Position Title:
Contact Person:
Phone:
Fax (Optional):
Woman-Owned:
Minority-Owned:
Veteran-Owned:

 Yes
 Yes
 Yes

Broker (if applicable):
Name of Brokerage:

 No
 No
 No

 Decline to answer
 Decline to answer
 Decline to answer

Contact Person:

E-mail: _______________________________________Phone number: ___________________Fax: _____________________________

1

Affiliations exist when one individual or entity controls or has the power to control another or when a third party or parties control or have the
power to control both. Factors such as common ownership, common management, previous relationships with or ties to another entity, and
contractual relationships may cause affiliation. The complete definition of affiliation is found at 13 C.F.R. § 121.103.
2
A company’s Primary Industry NAICS codes is the NAICS that accounts for the largest share of sales for the most recently completed fiscal year.
The full definition of “primary industry” is set forth at 13 C.F.R. § 121.107.

EIB 92-64 (Rev. 1/2019)

Page 1 of 8

OMB No. 3048-0018
PENDING 2019

1. GENERAL QUESTIONS
A. Type of Coverage Requested
 Comprehensive Risk (Political Risk and Commercial)

 Political Risk (Political Risk Only)

B. Qualification for Coverage
Will the Applicant have title to the products at the time they are shipped?
Will the Applicant directly invoice the Buyer?

Yes 
Yes 

No 
No 

If you answered No to either, you may not be eligible for coverage. Call EXIM or your Broker for assistance.
C. Primary Reason for applying for this policy
 Risk mitigation
 Financing
 Extend more competitive terms
D. Is this a resubmission of a previously withdrawn, returned or denied application, or a renewal policy
for the same Buyer or a related entity?
 Yes - If Yes, indicate previous transaction number:
 No

2. SPECIAL COVERAGES
Check the boxes in the table below for the special coverage that apply to this transaction and provide detailed
responses in the sections later in this form.
 Additional Named Insured
Do you want to insure sales by affiliated
companies?

 Bulk Agriculture

 Delivery to the Buyer in the U.S.

 Foreign Currency Coverage
Indicate Currency: _________________

 Overseas Warehouse Coverage

 Services (the exported item is a
service)

 Pre-Shipment Cover

 Other

3. PARTICIPANTS
Provide information on the additional participants to the transaction.
Buyer
The Buyer is the entity that contracts with the Exporter for the purchase of U.S. goods and services.
Buyer's Legal Name: __________________________________ Contact Person:
Position Title: _________________________________________ E-mail:
Business Address: ____________________________________ City: _____________________State/Province:
Postal Code: ________________ Country: ________________ Phone: __________________Fax: _____________________________

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OMB No. 3048-0018
PENDING 2019

Guarantor(s) (if applicable)
The Guarantor is the person or entity that agrees to repay the credit if the Buyer does not. Refer to the ShortTerm Credit Standards to determine in what circumstances personal or corporate Guarantors are required.
Is a Guarantor(s) involved in this transaction?  Yes

No
 A company?
If Yes, is the Guarantor:
 An individual
Guarantor’s Legal Name: ______________________________Contact Person:
Position Title: _________________________________________ E-mail:
Business Address: ____________________________________ City: _____________________State/Province:
Postal Code: ________________ Country: ________________ Phone: __________________Fax:
_____________________________

End-User (if different than Buyer and if already known)
The End-User is the foreign entity that uses the U.S. goods and services:
Check if the End-User is also the Buyer. 
End-User's Legal Name: _______________________________Contact Person:
Position Title: _________________________________________ E-mail:
Business Address: ____________________________________ City: _____________________State/Province:
Postal Code: ________________ Country: ________________ Phone: __________________Fax: ____________________________
Agent (not insurance Broker)
An Agent is a business entity or individual located in the country of the Borrower or Buyer who has assisted in
the sourcing, packaging, and/or preparation of a request for support from EXIM, and which will receive
compensation in some form for their services.
No
Is an Agent involved in the transaction?
Yes



If Yes, add the agent information below:

Agent's Legal Name: __________________________________Contact Person:
Position Title: _________________________________________ E-mail:
Business Address: ____________________________________ City: _____________________State/Province:
Postal Code: ________________ Country: ________________ Phone: _________________Fax: _____________________________
Related Parties
Describe any direct or indirect ownership or family relationship that exists between any of the participants.
If none, so indicate:
None

Primary Source of Repayment (PSOR)
The PSOR is the entity whose financial statements or credit information form the basis of EXIM’s evaluation of
reasonable assurance of repayment, i.e. the entity whose financial statements EXIM uses to supply calculate
the ratios for Short-Term Credit Standards compliance. For this transaction, indicate whether the PSOR is:
 Buyer
 Corporate Guarantor, or
 Business Combination, (e.g. the consolidated or combined financial statements of the Buyer and one or more
corporate Guarantors).
Indicate which entities comprise the combination:
Is the PSOR a financial institution?
 Yes
 No
Does the PSOR have a market rating?
 Yes
 No
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If Yes, indicate the name of the rating agency, rating, and the date of the rating:

OMB No. 3048-0018
PENDING 2019

4. TRANSACTION DESCRIPTION AND ELIGIBILITY
Indicate whether the sale represents a:
 Confirmed Order
 Sale in Negotiation

 Response to a Bid

Provide a description of the products or service, including their NAICS code.
Regarding the above products or services:
1.
2.
3.
4.
5.
6.
7.
8.

Are these products manufactured or reconditioned in the U.S.?
Yes No 
Are these products shipped from the U.S.?
Yes No 
Are these products on the Munitions Control list?
Yes No 
Are these products sold to military entities or security forces?
Yes No 
Are these products used to support nuclear energy?
Yes No 
Are the products used?
Yes No 
Are the products capital goods that will be used to produce exportable products?
Yes No 
(a) For SBA Defined Small Business Only: Was each of the products covered under the policy
manufactured or reconditioned with more than 50% U.S. content (comprised of all direct and indirect
costs including but not limited to, labor, materials, research and administrative costs, but excluding
net profit) with no value added after shipment?
Yes No 
(b) If the answer to 5(a) is “No” because one or more of your products contains less than 50% U.S.
content, then coverage is available for the U.S. content only in each product with less than 50% U.S.
content. Please indicate if you are seeking coverage for products with less than 50% U.S. content.
Yes No 
(c) If the answer to 5(a) is “No” you may also obtain coverage on an aggregated basis for all products
on an invoice, provided that a Content Report is submitted at the time of shipment (please see applicable
Fact Sheet for information on aggregation). Please indicate if you are seeking coverage on an
aggregated basis.
Yes No 
(d) For Non-SBA Defined Small Business: Was each of the products to be covered under the policy
manufactured or reconditioned with more than 50% U.S. content (comprised of all direct and indirect
costs including but not limited to, labor, materials, research and administrative costs, but excluding net
Yes No 
profit) with no value added after shipment?
(PLEASE NOTE THAT YOU MAY ANSWER “YES” TO EITHER OR BOTH (b) AND (c) ABOVE).

9. Do these products or their use meet EXIM’s requirements for an environmentally beneficial determination?
Yes No 
If yes, provide an explanation:
10. Do these products or their use meet EXIM’s requirements for an environmentally beneficial determination?
Yes No 
If yes, provide an explanation:
11. Will any value be added to the product after export from the U.S. prior to delivery to the Buyer?
Yes No 
If yes, provide an explanation:
12. Has the transaction been considered by any other export credit insurer?
EIB 92-64 (Rev. 1/2019)

Yes No 
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OMB No. 3048-0018
PENDING 2019

If yes, provide an explanation:

5. FINANCED AMOUNTS AND STRUCTURE
Enter the percentages for each payment term the exporter will extend to the Buyer:
Payment terms requested

(No. of days)
Sight

PAYMENT TYPE

Up to
30

Please check applicable box
Up to
60

Up to
90

Up to
120

Up to

180

Up to
270

Up to
360

Open Account
Cash Against Documents (CAD)
Promissory Note
Sight Draft Documents Against Acceptance (SDDA)
Sight Draft Documents Against Payment (SDDP)
Unconfirmed Irrevocable Letter of Credit (UILC)

Number of shipments:

Single

Multiple under one sales contract

Expected date(s) of shipment:
Estimated shipment volume to be insured:
If multiple shipments, expected highest amount outstanding during the shipment period:
Other security available:
Amount ready to ship:

6. Credit Information Requirements
Directions: The required credit information depends on whether the Primary Source of Repayment (PSOR)
is the Buyer or Corporate Guarantor, or a Financial Institution Guarantor, and on the amount of credit support
requested. Check the boxes that are applicable to your transaction.

The PSOR is a Private-Sector Company

The PSOR is a Financial Institution

Provide details of the Exporter’s experience with the Buyer
Does the Exporter have any experience selling to the Buyer? Yes
If Yes, provide the following information:
Date of first sale to the Buyer:
Date of first credit sale to the Buyer:
Historic credit experience with the Buyer:

EIB 92-64 (Rev. 1/2019)

No

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OMB No. 3048-0018
PENDING 2019

Yearly Credit Experience

Current Year

Prior Year 1

Prior Year 2

MM/YYYY to MM/YYYY

MM/YYYY to MM/YYYY

MM/YYYY to MM/YYYY

Total Amount Sold
Total Amount Sold on Credit
Highest Amount Outstanding
Exporter has been Paid
Payment Terms/Tenor

Amount now owing:
Payment history:

Prompt

Is there an amount past-due?

1-30 days slow
Yes

31-60 days slow

60+ days slow

No

If yes, enter amount due and due dates:
Provide reasons for past-dues:
If past-dues were caused by foreign exchange problems, does applicant have evidence of local currency
deposits on all payments due?

Yes

No

Please refer to the Short-Term Credit Standards found on our website to determine what information is
required in your application based on the dollar amount requested.

7. Pre-shipment Questionnaire
Details of Coverage Requested:
Provide the reason pre-shipment coverage is requested
Indicate the date the contract was executed or the anticipated date of signing
Indicate the estimated period between the contract date and the final shipment date
Provide a schedule of any progress payments made or to be made by the buyer or during the pre-shipment
period, or indicate none: ______________________________________________________________________________________

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OMB No. 3048-0018
PENDING 2019

8. Additional Named Insured Questionnaire (if required)
Legal Name: _____________________________________________________________________________________
Contact: _________________________________________________________________________________________
Business Address: ______________________________________________________________________________
City: ______________________________________________________________________________________________
State: ____________________________________________________________________________________________
Country: _________________________________________________________________________________________
Nine Digit Zip/ Postal Code: ______________________________________________________________________
Relationship to Applicant: ________________________________________________________________________
Contact: _________________________________________________________________________________________
Role in the transaction: __________________________________________________________________________
Email: ____________________________________________________________________________________________
Contact person: __________________________________________________________________________________

9. Overseas Warehouse Information
If you requested the Special Overseas Warehouse Coverage, answer the following questions:
Warehouse Type:


Owned or controlled by Exporter
Bonded Warehouse
✔

✔

✔
Other

Warehouse Location: City
State/Province
Country

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OMB No. 3048-0018
PENDING 2019

CERTIFICATIONS AND SIGNATURE
Please refer to the “Standard Certifications and Covenants for EXIM Applications” set forth in Form EIB 18-CN,
posted on the EXIM website at https://www.exim.gov/tools-for-exporters/applications-forms/complete-list (the
“Standard Certifications”). THE STANDARD CERTIFICATIONS ARE INCORPORATED INTO THIS APPLICATION
AS IF FULLY AND DIRECTLY SET FORTH HEREIN. When signing this application in the space provided below,
the undersigned authorized officer signing on the applicant's behalf certifies and represents that he or she is fully
authorized to sign on the applicant's behalf, and that HE OR SHE HAS READ the Standard Certifications referenced
above AND IS CERTIFYING AND COVENANTING, as appropriate, to all of the certifications, acknowledgments and
covenants set forth in the Standard Certifications.
Applicant further certifies that the representations made and the facts stated in this application and its attachments
are true and Applicant has not misrepresented or omitted any material facts. Applicant further covenants that if
any statement set forth in this application or in the Standard Certifications, becomes untrue, or is discovered to have
been untrue when made, Applicant will promptly inform EXIM of all such changes or discoveries. Applicant further
understands that in accepting or approving this application, EXIM is relying upon Applicant's statements set forth in
the application and in the Standard Certifications, and all statements and certifications to EXIM are subject to the
penalties for false or misleading statements to the U.S. Government (18 USC § 1001, et. seq.).
I,

, do hereby certify that I am the duly appointed and qualified
(Title)

of

and that as such I am authorized to execute this application
(Name of Applicant)

on behalf of

.
(Name of Applicant)

In witness whereof, I have hereunto signed my name this

day of __

__

. 20

.

NOTICES
The applicant is hereby notified that information requested by this application is done so under authority of the Export-Import Bank Act of 1945,
as amended (12 USC 635 et. seq.); provision of this information is mandatory and failure to provide the requested information may result in EXIM
being unable to determine eligibility for support. If any of the information provided in this application changes in any material way or if any of the
certifications made herein become untrue, the applicant must promptly inform EXIM of such changes. The information provided will be reviewed
to determine the participants’ ability to perform and pay under the transaction referenced in this application. EXIM may not require the information
and applicants are not required to provide information requested in this application unless a currently valid OMB control number is displayed on
this form (see upper right of each page). EXIM reserves the right to decline to process or to discontinue processing of an application.

Paperwork Reduction Act Statement: We estimate that it will take you about 1.5 hour(s) 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# 3048-0018 Washington,
D.C. 20503.

EIB 92-64 (Rev. 1/2019)

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