Form EIB 92-79 EIB 92-79 Broker Registration Form

OMB #3048-0024
PENDING 2020

Export-Import Bank of the United States (EXIM)
COMMISSIONED BROKER APPLICATION FORM

Subject to compliance with the terms and conditions of this Application and the attached Standards of Professional Conduct
and Service, an insurance broker may become registered with EXIM and eligible for commission payments under EXIM
export credit insurance policies if the broker is appointed as broker-of-record by the policyholder either by designation on
an insurance policy application or by separate letter. The commission payments shall be based on EXIM’s “Broker
Commission Schedule” in effect at the time of shipment in the brokered transaction.
Name of Brokerage:
Contact:
Address:
City:
Phone: (
)
Fax: (
)
Tax ID#:
DUNS #:
Other lines of brokeredInsurance:

Title:
PO Box:
State:

Zip:
Email:
No. of Employees:

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 EXIM’s website, and applicants seeking a broker are referred to the list.
Please indicate here if you DO NOT wish to have your name released.
APPLICATION REQUIREMENTS AND INSTRUCTIONS
1)
2)
3)
4)
5)

Sign and return the attached “Standards of Professional Conduct and Service”.
Attach a copy of a current, valid State resident insurance brokerage license indicating issuance and/or expiry date(s).
Attach a copy of the Declarations page from your current professional liability insurancepolicy.
Sign and return the attached “Authorization for Automated Deposits” form.
Submit a description of your business operations, which should include at a minimum: (i) relevant background and
history of your company; (ii) description of your expertise in export credit insurance products; (iii) your plan to
promote EXIM programs to U.S. exporters; and (iv) for any other individuals with your firm who are licensed
insurance brokers and will be broking EXIM products, provide a list of names of all such individuals and the
States in which they are licensed.
CERTIFICATIONS AND NOTICES

The Broker (it) CERTIFIES and/or ACKNOWLEDGES to EXIM the following:
1.

Debarment, Suspension and Delinquency. (a) Neither it nor its principals has been within the past 3 years (i) debarred,
suspended or declared ineligible from participating in or voluntarily excluded from participation in a “Covered Transaction”
defined in the Government wide Debarment and Suspension (Nonprocurement) regulations and the Export
Import Bank of the United States Debarment and Suspension (Nonprocurement) regulations.; (ii) formally proposed for
debarment, with a final determination still pending; (iii) or indicted, convicted or had a civil judgment rendered against
it for any of the offenses listed in the Government wide Debarment and Suspension (Nonprocurement) regulations; and
b)

Neither it nor its principals is delinquent on any amounts due and owing to the U.S. Government, its
agencies or instrumentalities as of the date of this application; and

c)

In connection with a transaction, it has not and will not knowingly enter into any agreements or affiliations
with any individual or entity to whom items (a) or (b) above apply; or
It has received a written statement of exception from EXIM and attached it to this certification,
permitting participation in the transaction despite an inability to make certifications (a)(i)1 (iii), (b) and (c).

d)

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2.

3.

4.

5.

6.

7.

8.

Lobbying. It will complete and submit SF Form1 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 for influencing or attempting to influence, in
connection with this application: (a) any officer or employee of any U.S. Government agency; or (b) any Member of
Congress or a Member’s employee; or (c) any officer or employee of Congress.
Corrupt Practices. Corrupt payments made in connection with Bank supported transactions may be a violation of the
Foreign Corrupt Practices Act of 1977 (15 USC 78dd1 l, et. seq.) or other applicable law or regulation 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.
Notice of Authority to Request Information. The broker is hereby notified that the information being requested is done
so under authority of the Export-Import Bank Act of 1945 (12 USC 635 et seq.) and other applicable laws and
regulations. Provision of this information is mandatory and failure to provide the requested information may result in
EXIM being unable to determine eligibility to be a registered broker for EXIM’s Insurance Program. The information
provided will be reviewed to determine if the broker meets EXIM’s requirements under the program.
EXIM may not require the information requested, 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).
Confidentiality and Disclosure Notice. EXIM will endeavor to restrict the disclosure of all information provided in this
form to the fullest extent permissible under federal information disclosure laws including the Freedom of Information Act
(5 U.S.C. 552), the Privacy Act of 1974 (5 U.S.C. 552a), or under any other law or court
order. EXIM 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 or for any other lawful purpose.
Public Burden Statement. We estimate that it will take you about 2 hours per response including reviewing
instructions, searching data sources, gathering information, completing, and reviewing the application. However, you
are not required to provide information requested unless a valid OMB control number is displayed on the form. Please
send comments regarding the burden estimate, including suggestions for reducing it to: Export Import Bank, Broker
Relations, 811 Vermont Ave., N. W. Washington, D.C. 20571 and Office of Management and Budget,
Paperwork Reduction Project, OMB # 30481 0024, 725 17th Street, N.W., Washington, D.C. 20503.
Standards of Professional Conduct and Service. The broker must sign the Standards of Professional Conduct and
Service in connection with this Application and every three years thereafter. EXIM reserves the right to withdraw or
rescind a broker’s registration with EXIM: (i) immediately for cause; or (ii) at any time, without cause, upon 30 days
prior written notice. "Cause" includes the breach of any applicable Standard of Professional Conduct and Service and
may also include other conduct such as, in EXIM's sole determination, an excessive claims history associated with
transactions brokered by such broker, or a reasonable belief that the broker was involved in fraudulent or wrongful
activity, or that the broker knew or should have known that a specific transaction was tainted by fraud. Removal
from the list of registered brokers will result in the cancellation of eligibility to receive commission payments from EXIM.
False Claims. The representations made by the broker 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 et seq.).

Signature:
Title:

Print Name:
Date:

Send this application to Attn: Broker Relations, EXIM,
811 Vermont Avenue, NW, Washington, D.C. 20571
The EXIM website is http://www.exim.gov

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EXIM INSURANCE BROKERS
STANDARDS OF PROFESSIONAL CONDUCT AND SERVICE
At all times while registered as a broker with EXIM, the broker (“you”) shall:
1. Act in a professional, reasonable, prudent and forthright manner and at all times with the utmost good faith and
integrity, in all dealings with your client and EXIM;
2. Make certain that your clients and third parties understand that you are neither an employee of EXIM nor an
official representative of EXIM;
3. Stay knowledgeable about not only EXIM export credit insurance but also alternatives, including other EXIM
programs, other U.S. government programs, and private sector products as well, in order to provide the best
options to your clients;
4. Educate yourself, agents, employees and your clients about EXIM’s insurance program and policies, including
their benefits and proper usage;
5. Serve as your clients’ primary contact for any questions concerning EXIM policies and procedures and the
servicing of an EXIM insurance policy;
6. Review all applications, issued policies, renewals of policies and credit limits, and claims, for timeliness,
completeness, accuracy and reasonableness;
7. Review correspondence from EXIM with your clients, including quotes and credit limits, to assist them in
understanding the coverage and their responsibilities;
8. Seek from clients information about their circumstances and objectives as might reasonably be expected to be
relevant in enabling the broker to fulfill its responsibilities to them;
9. Assist your clients to comply with the requirements of EXIM insurance policies, including shipment reports,
premium payment and reports of overdue accounts, reporting policy cancellations, submission of
premium reconciliation reports, notifications of defaults and filing claims;
10. Maintain knowledge of and comply with all applicable laws, rules, and regulations of any government agency, or
regulatory organization governing your professional, financial, or business activities;
11. Promptly disclose to EXIM, any termination of, or changes or suspensions related to, the insurance brokerage
license submitted in connection with this Application.
12. Disclose to clients any material conflict of interest that could reasonable be expected to impair the broker’s
ability to make an unbiased and objective decision when making recommendations or taking actions;
13. Organize and control the internal affairs of its insurance brokering business in a responsible manner, and where
staff are employed ensure that they are competent, suitable, and under adequate day-to-day supervision by a
registered insurance broker;
14. Take reasonable steps to give customers sufficient information in a comprehensible and timely way to enable
them to make balanced and informed decisions about EXIM’s export credit insurance policies; and
15. Prior to authorization, disclose to EXIM any fees or commissions received (or contemplated) related to, or any
other economic interest held in, the underlying transaction for which the broker is receiving EXIM commissions.
The undersigned hereby agrees to comply with the above Standards of Professional Conduct and Service and
acknowledges that the foregoing obligations are independent and separate from the obligations of the insured set
forth in any EXIM export credit insurance policy.
Name of Brokerage:
Print Name:
EIB 92-79
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Signature of Broker:
Date:
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AUTHORIZATION FOR AUTOMATED DEPOSITS
(ACH CREDITS)
I hereby authorize the Export-Import Bank of the United States hereinafter called EXIM, 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 EXIM has received written notification from me of its
termination in such time and in such manner as to afford EXIM a reasonable opportunity to act on it.
BROKER NAME
SIGNATURE:

DATE:

PLEASE ATTACH A VOIDED CHECK FOR THE ACCOUNT NAMED ABOVE

FOR EXIM 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
BROKER COMMISSION SCHEDULE
FOR EXPORT CREDIT INSURANCE POLICIES
BROKER ELIGIBILITY
Insurance brokers and agents are eligible for commission payments under EXIM export credit insurance policies if the broker
or agent is registered with EXIM 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.
COMMISSION RATES
Commission rates paid by EXIM 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: EXIMSmall Business* ........................... 40%
Multi-Buyer Policyholders: All others**. ......................................... 15%
Short Term Single-Buyer Policyholders: SBA Small Business ...........15%
Short Term Single-Buyer Policyholders: All others .......................... 10%
Medium Term Single-Buyer:............................................................10%
* EXIM Small Business is defined as an exporter that meets applicable SBA small business criteria and has average annual export
credit sales of ≤ $10 million over the past three years. If the exporter is also the borrower under an SBA or EXIM working capital
loan guaranty, the exporter receives a 25% discount on the applicable premium rate, and the broker commission increases to
50%.
**If the exporter is SBA Small Business but not EXIM Small Business, and is the beneficiary of an SBA or EXIM Working
Capital Loan Guaranty, the commission is 20%. If the exporter is also the borrower under an SBA or EXIM working capital loan
guaranty, the exporter receives a 25% discount on the applicable premium rate, and the broker commission increases to 20%.
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.
Who To Contact: For additional information, contact EXIM using the contact information below and ask for Broker Relations.
General Inquiries: TEL. 202.565.EXIM (3946) OR 1.800.565.EXIM (3946); FAX 202.565.3723; www.exim.gov; info@exim.gov
Paperwork Reduction Act Statement: We estimate that it will take you about 1/4 hour 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# 3048-0024; Washington, D.C. 20503.

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