Application for a master insurance policy for

Transcription

1 page 1 of 5 Application for a master insurance policy for tied buyer credit P5D the purchase of receivables P5F WE REQUEST the assumption of a new policy the increase of existing policy no. a maximum amount of EUR APPLICANT (INSURANCE POLICY HOLDER/PAYER) SUPPLIER/SERVICE PROVIDER CONTRACTUAL PARTNER Identification data Registration number and/or VAT number OeKB Versicherung a brand of Acredia Versicherung AG 1010 Vienna, Weihburggasse 30, Tel , Fax Linz, Robert-Stolz-Straße 7, Tel , Fax registered office: Himmelpfortgasse 29, 1010 Vienna, Commercial Court Vienna, reg. no: 59472i, DPR: , VAT no: ATU , IBAN: AT , BIC: OEKOATWW

2 page 2 of 5 Application for a master insurance policy for TRANSACTION INFORMATION Goods/service Recipient/destination country of the goods/service (if different from the contractual partner) Payment terms Guarantees (amount, date issued, name and address of guarantor) Letter of credit Bank guarantee Joint liability Other BUSINESS RELATIONSHIP OF SUPPLIER/SERVICE PROVIDER WITH THE CONTRACTUAL PARTNER New customer Customer Last year s revenue in EUR Current year s revenue in EUR Current receivables in EUR Oldest open invoice of EUR from due

3 page 3 of 5 Application for a master insurance policy for CURRENT CREDITWORTHINESS INFORMATION ON CONTRACTUAL PARTNER/JOINTLY LIABLE PARTY has already been provided to OeKB Versicherung/is enclosed. will be sent in later. is not required as there is a letter of credit. will be requested by Oesterreichische Kontrollbank AG at our expense. Has the requested transaction already been submitted to another credit insurer? yes no We will send on the following documents later Space for additional comments, particularly negative information regarding the contractual partner We hereby acknowledge that the policy is only accepted on the basis of the details in the application. The correctness of these details, any documents provided and the validity of the insured rights will not be checked until an insurance claim is processed. We expressly agree to our data being transferred by Acredia Versicherung AG to group companies and reinsurers. (Group companies can be found online on the website of OeKB Versicherung an Acredia Versicherung AG brand at We agree to Acredia Versicherung AG using our data when sending product and customer information. We can revoke our agreement at any time in writing. All information received by Acredia Versicherung AG about customers or third parties will be treated as strictly confidential. We obtain this information without any obligation to Acredia Versicherung AG. We therefore waive any claims that we may have against Acredia Versicherung AG as a result of such confidential communications. We agree to indemnify Acredia Versicherung AG against any claims by third parties who may become aware of such confidential information. We confirm receipt of the terms and conditions regarding revolving insurances for tied buyer credit and the purchase of receivables (2011 version) master insurance policies (P5D), (P5F) as well as inclusive insurances (P6D), (P6F) and hereby declare that we recognise these terms and conditions as part of the contract.

4 page 4 of 5 Application for a master insurance policy for We acknowledge that the terms and conditions and the applicable policy are binding for the legal relationship between Acredia Versicherung AG and us. WE REQUEST ACCESS AUTHORISATION FOR THE FOLLOWING EMPLOYEES FOR THE OEKB VERSICHERUNG ONLINE SERVICE (IF NONEXISTENT) Title Mrs/Miss/Ms Mr Title First name Last name Telephone (ext.) I would like to receive daily updates by on new incoming documents across the company. Title Mrs/Miss/Ms Mr Title First name Last name Telephone (ext.) I would like to receive daily updates by on new incoming documents across the company.

5 page 5 of 5 Application for a master insurance policy for We agree to the conditions of use for the online service of Acredia Versicherung AG for the OeKB Versicherung brand (as of 1 August 2014, available from the download centre). The OeKB Versicherung online service will send us the user names and passwords via post within the next few days. This confirms that the request has been accepted and the online service can be used immediately. SEPA Direct Debit Mandate already provided SEPA DIRECT DEBIT MANDATE Payee Creditor ID Acredia Versicherung AG, Himmelpfortgasse 29, 1010 Vienna AT30ZZZ I/we authorise Acredia Versicherung AG for the OeKB Versicherung brand to draw payments on my/our account via Direct Debit. In addition, I instruct my/we instruct our bank to honour the Direct Debits drawn by Acredia Versicherung AG on my/our account. I/we agree to a deadline of five calendar days for advance notice of the SEPA Direct Debit. Note: I/we may request a refund of the debited amount within eight weeks of the date on which the amount was debited. This is subject to the terms agreed with my/our bank. Payer IBAN BIC Place and date Administrator Telephone Fax number Applicant s/payer s authorised signature