Application Form. Formulaire de Demande de Souscription. 27B, Riverside Street, Coromandel, Mauritius BRN C FSC Licence no.
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1 Application Form Formulaire de Demande de Souscription 27B, Riverside Street, Coromandel, Mauritius BRN C
2 YOUR COMPANY NAME NOM DE VOTRE ENTREPRISE REGISTERED ADDRESS / COUNTRY ADRESSE DU SIEGE SOCIAL / PAYS COMMERCIAL ADDRESS / COUNTRY ADRESSE COMMERCIALE / PAYS COMPANY REG. No. No. D ENREGISTREMENT INSURABLE BUSINESS ACTIVITY ACTIVITE ASSURABLE Export Domestic/Domestique DESCRIPTION OF THE BUSINESS ACTIVITY DESCRIPTION DE L ACTIVITE Do you belong to a group of companies? Faites-vous partie d un groupe? No / Non Yes / Oui Which one /lequel Do you have any subsidiaries? Avez-vous des filiales? No / Non Yes/ Oui Which one /Lequel Where/dans quel pays? CONTACT PERSON INTERLOCUTEUR POSITION FONCTION TEL /MOBILE COURRIEL Page 1/4
3 INSURABLE TURNOVER / CHIFFRE D AFFAIRE ASSURABLE CURRENCY/DEVISE EUR USD LAST KNOWN TURNOVER DERNIER CA CONNU CREDIT SALES VENTES A CREDIT DOWN PAYMENT / LCs ACCOMPTES / LC SALES TO RELATED COMPANIES VENTES A DES SOCIETES LIEES EXPORT DOMESTIC TOTAL PAYMENT TERMS / CONDITIONS DE PAIEMENT DISTRIBUTION REPARTITION DOWN PAYMENT ACCOMPTE CASH ON DELIVERY PAIEMENT A LA LIVRAISON 30 DAYS 30 JOURS 60 DAYS 60 JOURS 90 DAYS 90 JOURS STANDARD LC LC STANDARD CONFIRMED LC LC CONFIRMEE % % % % % % % OBSERVATIONS MAXIMUM DSO (days sales outstanding) : DAYS / JOURS DELAIS MAX. DE PAIMENT DEBTORS OUTSTANDING BALANCE / DECOUVERTS CLIENTS CURRENCY DEVISE EUR USD < FROM TO DE 5,001 A 10,000 FROM TO DE 10,001 A 50,000 FROM TO DE 50,001 A 100,000 FROM TO DE 100,001 A 150,000 ABOVE PLUS DE 150,000 NUMBER OF CLIENTS NOMBRE DE CLIENTS Page 2/4
4 DEBTORS OUTSTANDING BALANCE / DECOUVERTS CLIENTS CURRENCY / DEVISE EUR USD TOTAL AMOUNT MONTANT TOTAL YOUR HIGHEST OUTSTANDING BA LANCE FOR A YEAR VOTRE PLUS GROS ENCOURS POUR UNE ANNEE YOUR HIGHEST OUTSTANDING BA LANCE FOR A DEBTOR VOTRE PLUS GROS ENCOURS POUR UN DEBITEUR MAIN CLIENTS / PRINCIPAUX CLIENTS CURRENCY / DEVISE EUR USD COUNTRY PAYS COMPANY NO. No. D ENREGISTREMENT CLIENTS NAME + ADDRESS NOM DES CLIENTS + ADRESSE OUTSTANDING BALANCE MONTANT DE L ENCOURS BAD DEBTS / IMPAYES YEAR ANNEE COMPANY NO. No. D ENREGISTREMENT CLIENTS NAME + ADDRESS NOM DES CLIENTS + ADRESSE BAD DEBT AMOUNT MONTANT DE L IMPAYE REASON RAISON Page 3/4
5 DEBTS MANAGEMENT SOLUTIONS GESTION DU POSTE CLIENT ARE YOU CREDIT INSURED? YES / OUI NO / NON ETES-VOUS ACTUELLEMENT ASSURE CREDIT? DO YOU HAVE A FACTORING AGREEMENT? YES / OUI NO / NON AVEZ-VOUS ACTUELLEMENT UN CONTRAT D AFFACTURAGE? DO YOU WISH TO RECEIVE A PROPOSAL FOR CREDIT INSURABCE (1) FACTORING (2) SOUHAITEZ-VOUS RECEVOIR UNE PROPOSITION D ASSURANCE-CREDIT D AFFACTURAGE (1) For insuring domestic sales a derogation should be requested to the FSC as per the Insurance Act 2005 (2) Should you wish a Factoring contract, an assessment regarding your receivables will be conducted PIECES JOINTES AU DOSSIER / ENCLOSED DOCUMENTS DERNIER BILAN / LAST FINANCIALS CERTIFICAT D INCORPORATION / INCORPORATION CERTIFICATE BRN (BUSINESS REGISTRATION CARD) The information provided in this request form does not constitute a commitment towards the credit insurer. You confirm that the information provided in this form is true and accurate. Should this information change, you agree to immediately inform the service provider. Should you choose to implement credit insurance solution; your company gives exclusive mandate to Risk Shield Ltd for any negotiation action regarding a credit insurance contract with any credit insurer. The present mandate supersedes any previous mandate and has a validity of 6 months as from date of signature. READ AND APPROVED LU ET APPROUVE Done in Port-Louis/ Fait à, Mauritius on/le / / 2016 SIGANTURE Name and position of the signatory Nom et fonction du représentant de l entreprise Company stamp Cachet commercial de l entreprise Broker stamp Cachet commercial du courtier Page 4/4
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