Form EIB 10-03 EIB 10-03 Notice of Claim and Proof of Loss Short-Term Insurance

OMB No.: 3048-033
PENDING 2024

NOTICE OF CLAIM AND PROOF OF LOSS
SHORT - TERM INSURANCE
This Notice of Claim and Proof of Loss –Short Term Insurance application is for requesting a claim payment under the EXIM
Short Term Insurance program. An on-line version of this Notice of Claim and Proof of Loss is available on EXIM’s website.
EXIM encourages customers to submit in EXIM Online, https://eximonline.exim.gov/apps/bap, as it will facilitate EXIM’s review
and provide customers a faster response time.
SECTION A - NAMES AND ADDRESS (please provide full names and addresses)
Insured:

Click here if not applicable:

Name:
Contact:

Address:
City:

State:

Zip Code:

Phone No.:

Country:

Assignee:

Click here if not applicable:

Name:
Contact:

Address:
City:

State:

Zip Code:

Click here if not applicable:

Name:

Address:

Contact:

City:

State:

Zip Code:

Country:

Exporter:

Click here if not applicable:

Name:
Contact:

City:

State:

Zip Code:

Click here if not applicable:

Name:
Contact:

Address:
City:

State:

Zip Code:

Email:
Phone No.:

Country:

Click here if not applicable:

Name:

Address:

Contact:

City:

State:

Zip Code:

Country:

Manufacturer

Email:
Phone No.:

Country:

Guarantor:

Email:
Phone No.:

Address:

Buyer:

Email:
Phone No.:

Country:

Broker:

Email:

Email:
Phone No.:

Click here if not applicable:

Name:

Address:
City:

Contact:
State:

Zip Code:

Country:

EIB 10-03 (Rev. 04/2024)

Email:
Phone No.:

Page 1 of 5

OMB No.: 3048-033
PENDING 2024

SECTION B - POLICY INFORMATION
Policy

Buyer Credit Limit (IBCL/SBCL)

Policy Type:

Amount:

Policy Number:

Effective Date of IBCL/SBCL:

Policy Effective Date:

Buyer Credit Limit (DCL)

Policy Expiry Date:

 Ledger

Policy Credit Limit:

How was the Buyer Credit Limit determined?

Policy Claim Payment Limit:

 Credit report
 Trade reference

For ESS Policy, is this a pre-pay option?

 Yes

 No

Policy Shipment Volume

Maximum Credit Limit:
Max. High Credit Outstanding during 12 mos.
prior to shipment of first claimed invoice:

Policy Assignment
Is the Policy Assigned?

 Yes

 No

Assignment Date:

Any limits in effect are noncumulative. Only one credit limit can be in effect for
the buyer/issuing bank on the date of shipment.

SECTION C - CLAIM INFORMATION
Did the buyer accept delivery of the
product?

Date(s) Shipped/Funded:
Original Credit Terms:

What is the first Default Date?
What is the reason for the Claim filing?

Products:
Special Conditions, if
applicable

 Yes

 Security Interest
 Guarantors
 Other _______________________

For ELC Policies only

Was pre-presentation agreement
elected?

 Yes  No
Commitment Date:

The Issuing Bank's obligation
is based on:

Date of 1st Presentation of Documents:

SECTION D - DOCUMENTATION & CERTIFICATIONS
D1. Required Documents:

Invoice(s)
Bill of Lading
Purchase Order(s) and/or Contract of Sale
Promissory Note (copies)
Collection Effort
Acceptance Advice
Nonpayment Advice
Evidence of Funding
Written demand of payment from the Buyer, Borrower or Issuing Bank
Written demand of payment from each guarantor
Draft (copies)
Evidence of required Security Interest
Credit Report(s)
Other Insurance
Documents supporting the Special Conditions of the Policy
Letter of Credit
Credit Agreement(s)
Exporter's Certificate
EXIM approved extensions or waivers
Claim Certification
Release and Assignment

EIB 10-03 (Rev. 04/2024)

Page 2 of 5

 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed
 Enclosed

 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable
 Not Applicable























Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow
Will Follow

 No

OMB No.: 3048-033
Expires: xx/xx/xxxx

D2. Other Documents: Please list other supporting your claim. To avoid processing delays, please provide all applicable items.
Other documents supporting your claim

 Enclosed
 Enclosed
 Enclosed

 Not Applicable
 Not Applicable
 Not Applicable

 Will Follow
 Will Follow
 Will Follow

D3. Comments: Use the space provided below to add any comments you wish to make regarding this claim, including a summary of the events leading up to
this claim.

SECTION E1 - SCHEDULE OF SHIPMENTS All outstanding insured shipments made to the buyer must be scheduled and included with this claim. For example, if there are two insured invoices outstanding
to a buyer and only one is eligible for claim filing at this time, the second invoice should be included as part of this claim filing. For each shipment, attach and
group together the invoice, bill of lading, purchase order, debt instrument, and any related documents. The bill of lading date is the date of shipment for purposes
of this schedule.
Interest calculations reflecting the dollar amount of the contract interest due for each invoice must be included in the column listed below.
Invoice
Number

Shipment
Date

Contract/
Payment Terms
Invoice Amount

Due Date

Principal Partial Interest Rate, if
Payment
applicable

Interest Partial
Date Interest
Payments, if
Paid Through
applicable

Month
Shipment
Reported

Total Gross Invoices: _____________________________
Are there any uninsured outstanding amounts with this buyer?

 Yes  No

If yes, please indicate how much ____________________
Why are these shipments uninsured? ____________

SECTION E2 - PROMISSORY NOTES - FIBC Only
Note Information
Attach a separate schedule for each note.
Have Promissory Note in Possession?

Check here if not applicable:

 Yes  No

Frequency of payments:

Date of Promissory Note:

Interest rate:

Total Principal Amount:

Rate Method of Calculation:

Number of Installments:
Date 1st Principal Due:

EIB 10-03 (Rev. 04/2024)

Principal:

Interest:

 Fixed
 360/365
Days

 Floating

360/360
Days

Date Ordinary Interest Paid Through:

Date 1st Interest Due:

Page 3 of 5

Have partial payments been applied to
defaulted installments?

 Yes

 No


365/365
Days

OMB No.: 3048-033
PENDING 2024
Installment Information (Provide complete amortization schedule for each note)
Installment Due
Installment
Declining Outstanding
Date(s)
Principal Due Principal Paid Outstanding Principal
Number(s)
Principal Balance
MM/DD/YYYY

Interest Due

Interest Paid

Interest Rate

Installment(s) - Additional Comments:

SECTION F - CALCULATION OF ELIGIBLE LOSS
Total contract amount of all insured shipments (principal only): ______________________________________
(EXIM will calculate the interest due based on the interest coverage of the Policy)
(a) (-) Total buyer payments applied to principal: ______________________________
(b) (-) Other credits, discounts, and allowances: _________________________________
(c) (-) Funds received from any other source: ______________________________
(d) (-) Savings because of nonpayment of agent's commission: _______________________
Net Loss: _________________________
Note: your final amount may be reduced by any unmet deductible per policy period.
Was interest specified in the buyer obligation:

 Yes

 No

If yes, (a) was ordinary interest charged to the due date:

 Yes

(b) was late interest charged after the due date:

 No

 Yes

 No

SECTION H - LEDGER EXPERIENCE
INSTRUCTIONS:
1. Complete the following schedule, listing all shipments made during the year prior to the first claimed shipment.
2. Be specific regarding the credit terms extended to the buyer for each shipment.
3. Check the box if there is no ledger experience with the buyer within the last 12 months.

Invoice Number

EIB 10-03 (Rev. 04/2024)

Amount

Terms

Shipment Date

Page 4 of 5

Due Date

Date Paid

Amount Paid

OMB No.: 3048-033
PENDING 2024

SECTION I - U.S. CONTENT REQUIREMENTS
1. For SBA Defined Small Businesses Only:
(a) Was each of the products on the claimed invoices manufactured or reconditioned in the United States 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
profit)?
 Yes  No
If the answer to 1(a) is “No”, you are still eligible for coverage for the value of the U.S. Content (as defined above) of each product. Please
attach a list with invoice number, product name and U.S. content percentage for each product that was manufactured or reconditioned with
50% or less U.S content.
(b) If you completed and submitted a Content Report with respect to each invoice at the time of shipment, you may submit a claim based on the
percentage of the aggregate U.S. content (as defined above) of all products claimed on the invoice. Is the U.S. content percentage of all
products on each claimed invoice, in the aggregate, more than 50% of the entire value of the invoice?
 Yes  No
If the answer to 1(b) is “No”, you are still eligible for coverage of the aggregate value of the U.S. content of each invoice. Please attach a list
with invoice number, and U.S. content percentage for each invoice that has an aggregate U.S. content percentage of 50% or less.

2. For Non‐SBA Defined Small Businesses:
Was each of the products on the claimed invoices manufactured or reconditioned in the United States with more than 50% U.S. content
comprised of labor, materials, and direct overhead, but exclusive of profit)?
 Yes  No

SECTION J – NOTICES AND SIGNATURE
Name of Lender’s Authorized Representative: ____________________________________________________
Title: _____________________________________________________________________________________
Name of Lender: ___________________________________________________________________________
Street Address: ____________________________________________________________________________
City: ___________________________________________
State/Province: ___________________________________

Postal Code: _________________

Email: ____________________________________________________________________________________
Phone Number: ____________________________________________________________________________

NOTICES
Please refer to the Insured Certifications for Notice of Claim and Proof of Loss – Export Credit Insurance Policy posted on EXIM’s website as document
EIB 22-07. THE CERTIFICATIONS ARE INCORPORATED INTO THIS NOTICE OF CLAIM AND PROOF OF LOSS – EXPORT CREDIT INSURANCE POLICY
AS IF FULLY SET FORTH HEREIN. When signing this Notice of Claim and Proof of Loss in the space provided below, the undersigned authorized representative
signing on the Insured’s behalf certifies and represents that the undersigned is fully authorized to sign on the Insured’s behalf, and that THE UNDERSIGNED HAS
READ the Lender Certifications for Notice of Claim and Proof of Loss – Export Credit Insurance Policy referenced above AND IS CERTIFYING, as appropriate, to
all of the certifications set forth in that document.

The Lender 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 any application.

Paperwork Reduction Act Statement: We estimate that it will take you about 6 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 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# 3048-0035 Washington, D.C. 20503

EIB 10-03 (Rev. 04/2024)

Page 5 of 5