EIB 23-02 Application for Equity Express Select Insurance

E}{IM

EXPORT-IMPORT BANK
OF THE UNITED STATES

0MB No.: 3048-XXXX
Pending 2023

APPLICATION FOR EQUITY EXPRESS SELECT INSURANCE

Print Form

Items marked with an asterisk(*) are required fields. Under corporate ownership, provide name of ultimate parent company, if there is a corporate owner. For
number of employees and sales volume, aggregate for the company and all its affiliates 1, including corporate owners and subsidiaries.
*Exporter Legal Name:
D&B#: _________ Tradestyle:

*Total Number of Employees: ______

Business Address:

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*Zip+ 4: ____ *Annual Sales V olume: ______________

*State:

*City:

Country:_________ Contact Person:________ *Woman-owned business:
Position Title: ________ Phone #:

*Minority-owned business:

Yes

0No

Yes

0No

Race (One or more boxes may be selected.):

E-mail:

Decline to Answer

Decline to Answer

D American Indian or Alaska Native D Asian

*Primary Industry NAICS :

□

Brokerage: ----------------------

How did you learn about EXIM?
D EXIM City/State Partner

Yes

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Hispanic or Latino

Not Hispanic or Latino

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*Veteran-owned business:

0Yes

0No

D Decline to Answer

*Disability-owned business:

0Yes

0No

Decline to Answer

D EXIM Regional Office D Broker D Bank D U.S. Export Assistance Center

D Other

1. Primary reason for application:

□

O

Ethnicity:

2

*Does the exporter have any affiliates?

D Native Hawaiian or Pacific Islander

D Black or African American
0 White
Other

*Corporate Ownership: ________________
_

(describe):

D risk mitigation D financing

D extend more competitive terms

2. Do you have a credit line with a financial institution (exclude overdraft protection and credit cards)
3. Do you have a SBA export Working Capital Loan or EXIM Working Capital Loan?

DYES

SBA DYES

4. Average total of annual export credit sales over the last three years for you and your affiliates:

$

D NO

□

EXIM

NO

O YES O NO

----------

5. Do you wish to insure export credit sales made by your affiliates? (If yes, please attach names/business addresses of each)
Are the products of each affiliate the same as the applicant's?

If no, list them in question #6.

DYES D NO

Does each affiliate invoice export credit sales in its own name or trade style?
Are the credit decisions of each affiliate centralized with this applicant?

DYES D NO

DYES D NO

DYES D NO

If 'No,' provide comment:

6. Product and/or services to be exported & NAICS (if known):
7. Are the products: D New

D Used

8. Do you sell Capital Goods to foreign manufacturers or producers?
9. Are the Products to be covered under the policy:
Manufactured or reconditioned in the U.S.?
Shipped from the U.S.?
Sold to Military entities or Security Forces?
Environmentally Beneficial?

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YES
YES
YES
YES

0
0
0
0

DYES D NO

(if yes, attach explanation)

NO

All made or reconditioned with more than 50% U.S.
content?
(If no, attach explanation)

NO

Used to support Nuclear Energy?

NO

On the U.S. Munitions List?
(part 121 of title 22 of the Code of Federal Regulations)

NO

Supporting Renewable Energy?

□
□
□
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YES
YES
YES
YES

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□
□
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NO
NO
NO
NO

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 23-02 (Re v. 11/2023)

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0MB No.: 3048-XXXX
Pending 2023
10. For SBA defined Small Businesses Only:
A. 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
DYES DNO
excluding net profit)?
B. If the answer to (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
DYES DNO
products with less than 50% U.S. content.
C. If the answer to (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 Sheets for information on aggregation). Please
indicate if you are seeking coverage on an aggregated basis. Please note that you may answer "Yes" to either or both (b) and
0 YES ONO
(c).
11. Policy Payment Limit Requested: $

________

(maximum export credit receivables outstanding at any one time)

12 Year you began: a) Exporting? ___ b) Exporting on credit terms (other than cash in advance or confirmed letters of credit)? ______
13. For the last three years what were your total export credit: (include factored or insured receivables and attach any comments)
# of accounts written off

Losses

Sales

14. How many foreign buyers do you currently sell to on credit terms?
15. Total export credit receivables outstanding$

----

of which$

is more than 60 days past due at

(date must be within 30 days of application date)

17. Requested credit amount ____ & terms: -----days
required for a buyer you wish to insure. Provide full Buyer Name/Address:
Name
Business Address-------------------City
Zip Code
State
Country

16. Your most recent FYE date
NET Sales
Operating Profit
NET Profit or (Loss)
Total Assets
Equity

Note: Your buyers, their guarantors (if any), and end users of the products must be in countries where EXIM is able to provide support, see
EXIM's Country Limitation Schedule (CLS) at http://www.exim.gov. There may not be trade measures or sanctions against the good
produced with the U.S. export under Section 201 of the Trade Act of 1974. For a list of products and countries with Anti-Duping or
Countervailing Duty sanctions, see section AD/CVD Orders available at http://www.usitc.gov/trade remedy/731 ad 701 cvd/
investigations/active/index.htm. Trade sanctions are product and country specific (i.e., all firms within a country are subject to the order,
unless a specific firm is explicitly excluded).

Buyer Information
1. Do you have any ownership interest in or familial ties with the buyer?

2. Will the products be shipped directly to the buyer in the buyer's country?

DYES D NO

D YES DNO

3. Is the buyer purchasing your product(s) for resale to another country/countries?

4. Any prior sales to the buyer?

If Yes, comment below

If No, comment below

DYES DNO

If Yes, comment below

DYES D NO

�-----�

5. List the year of your first sale to the buyer. �-----�
6. Any prior sales to the buyer on credit terms? Exclude any Cash-in-Advance or Letter of Credit sales.

DYES DNO

7. List the year of your first sale to the buyer on credit terms. Exclude any Cash-in-Advance or Letter of Credit sales.

EIB 23-02 (Rev. 11/2023)

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0MB No.: 3048-XXXX
Pending 2023
8. Enter the total sales made to the buyer on credit terms over the last three years. Enter "0" if the buyer is new to you.$
9. Describe the payment terms extended to the buyer over the last twelve months:
Transaction Type �--------�

Maximum Tenor

10. What is the highest amount outstanding over the last twelve months for which you have been paid? $
11. Describe the buyer's history over the last twelve months:

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Prompt

01-30 days slow

031-60 days slow

061-90 days slow

12. What is the amount now owed to you by the buyer? Enter "O" if none. $
13. What is the total amount now more than 60 days past due? Enter "0" if none. $

090+ days slow

D No experience

14. What is the reason for the buyer being past due to you?

15. Do you hold security on the amount past due?

EIB 23-02 (Rev. 11/2023)

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YES

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NO

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0MB No.: 3048-XXXX
Pending 2023

CERTIFICATIONS AND SIGNATURE
Please refer to the "Standard Certifications and Covenants for EXIM Applications" set forth in Form EIS 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 0MB 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 0.25 hours 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 0MB
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# 3048-0031 Washington, D.C. 20503.

EIB 23-02 (Rev. 11/2023)

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