Form EIB 24-06 EIB 24-06 NOTICE OF CLAIM AND PROOF OF LOSS MEDIUM - TERM INSURANC

OMB No 3048-xxx
PENDING 2024

NOTICE OF CLAIM AND PROOF OF LOSS
MEDIUM - TERM INSURANCE
This Notice of Claim and Proof of Loss – Medium Term Insurance application is for requesting a claim payment under the
EXIM Medium 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:

Email:

Zip Code:

Phone No.:

Country:

Assignee:

Click here if not applicable:

Name:
Contact:

Address:
City:

State:

Email:

Zip Code:

Phone No.:

Country:

Broker:

Click here if not applicable:

Name:

Address:

Contact:

City:

State:

Zip Code:

Email:

Country:

Exporter:

Phone No.:

Click here if not applicable:

Name:
Contact:

Address:
City:

State:

Email:

Zip Code:

Phone No.:

Country:

Buyer:

Click here if not applicable:

Name:
Contact:

Address:
City:

State:

Zip Code:

Email:
Phone No.:

Country:

Guarantor:

Click here if not applicable:

Name:

Address:

Contact:

City:

State:

Zip Code:

Email:

Country:

Manufacturer

Phone No.:

Click here if not applicable:

Name:

Address:
City:

Contact:
State:

Zip Code:

Email:

Country:

EIB 24-06 (04/2024)

Phone No.:

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OMB No 3048-xxxx
PENDING 2024

SECTION B – POLICY AND ASSIGNMENT INFORMATION
Policy Type:

(Total) Financed Portion approved:

Policy Number:

Policy Payment Limit:

Policy Effective Date:

Is the Policy Assigned?

Policy Expiry Date:

Assignment Date:

 Yes

 No

SECTION C - CLAIM INFORMATION

Funding date(s):

Did Buyer accept delivery of the
product?
The first Default Date?

Original Credit Terms:

Default Reason:

Shipping date(s):

 Yes

 No

Product:
Special Conditions
applicable:

 Security Interest
 Guarantors
 Other

SECTION D - DOCUMENTATION AND CERTIFICATIONS
D1. Required Documents: To avoid processing delays, please provide all applicable items.
Invoice(s)

 Enclosed

 Not Applicable

 Will Follow

Bill(s) of Lading

 Enclosed

 Not Applicable

 Will Follow

Purchase Order(s) and/or Contract of Sale

 Enclosed

 Not Applicable

 Will Follow

Promissory Note (copies)

 Enclosed

 Not Applicable

 Will Follow

Collection Effort

 Enclosed

 Not Applicable

 Will Follow

Acceptance Advice

 Enclosed

 Not Applicable

 Will Follow

Evidence of Funding

 Enclosed

 Not Applicable

 Will Follow

Evidence of cash payment

 Enclosed

 Not Applicable

 Will Follow

Written demand of payment from the Buyer/Borrower

 Enclosed

 Not Applicable

 Will Follow

Written demand of payment from each guarantor

 Enclosed

 Not Applicable

 Will Follow

Evidence of required Security Interest

 Enclosed

 Not Applicable

 Will Follow

Beneficiary Certificate

 Enclosed

 Not Applicable

 Will Follow

Relevant Correspondence
Documents supporting compliance with the Special Conditions of
the Policy
Credit Agreement(s)

 Enclosed

 Not Applicable

 Will Follow

 Enclosed

 Not Applicable

 Will Follow

 Enclosed

 Not Applicable

 Will Follow

Exporter's Certificate(s)

 Enclosed

 Not Applicable

 Will Follow

EXIM approved extensions or waivers

 Enclosed

 Not Applicable

 Will Follow

Completed EXIM Claim Certification form

 Enclosed

 Not Applicable

 Will Follow

Release and Assignment

 Enclosed

 Not Applicable

 Will Follow

 Enclosed

 Not Applicable

 Will Follow

 Enclosed

 Not Applicable

 Will Follow

 Enclosed

 Not Applicable

 Will Follow

 Enclosed

 Not Applicable

 Will Follow

 Enclosed

 Not Applicable

 Will Follow

D2. Other Documents: Please list other documents supporting your claim.

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.

EIB 24-06 (04/2024)

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OMB No 3048-xxxx
PENDING 2024

SECTION E - PROMISSORY NOTE(S)
Note Information
Attach a similar schedule for each note.
Have Promissory Note in

Check here if not applicable:
 Yes  No

Frequency of payments:

Possession?
Date of Promissory Note:

Interest rate:

Note Amount:

Rate Method of Calculation:

Number of Installments:

Principal: ______Interest: _______

Date 1st Principal Due:

 Fixed

 Floating







360/365

360/360

365/365

Days

Days

Days

Interest Rate Basis:  SOFR  PRIME  OTHER _____________

Date 1st Interest Due:

Have partial payments been applied to
defaulted installments?

 Yes

 No

Installment Information (Provide complete amortization schedule for each promissory note)
Installment
Number

Installment
Due Date(s)
MM/DD/YYYY

Declining Outstanding
Principal Balance

Principal Due

Additional Comments:

EIB 24-06 (04/2024)

Page 3 of 4

Principal Paid

Interest Due

Interest Paid

Interest Rate
(%)

OMB No 3048-xxxx
PENDING 2024

SECTION F - CALCULATION OF ELIGIBLE LOSS
Total Promissory Note Amount of all insured shipments (principal only):
(-) Total Principal payments received:
Subtotal Loss:
(+) Unpaid Interest:
Net Loss:

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

Postal Code: _________________

Email: ____________________________________________________________________________________
Phone Number: ____________________________________________________________________________
Signature: ______________________________________

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 24-06 (04/2024)

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