5005001020 page 1 of 5 Request for insurance for direct deliveries and/or services P1 WE REQUEST the assumption of a P1 policy the assumption of an O1 offer the conversion of offer. into a P1 policy a maximum amount of EUR WE ARE APPLYING FOR CONTRACTUAL INTEREST COVER for EUR APPLICANT (INSURANCE POLICY HOLDER/PAYER) Full company name and address CONTRACTUAL PARTNER Full company name and address Identification data Registration number and/or VAT number OeKB Versicherung a brand of Acredia Versicherung AG 1010 Vienna, Weihburggasse 30, Tel. +43 1 531 27-2664, Fax -5691 4020 Linz, Robert-Stolz-Straße 7, Tel. +43 732 666 396-9412, Fax -9426 www.oekbversicherung.at, registered office: Himmelpfortgasse 29, 1010 Vienna, Commercial Court Vienna, reg. : 59472i, DPR: 0578410, VAT : ATU 15367608, IBAN: AT08 1000 0314 0508 0005, BIC: OEKOATWW
page 2 of 5 Request for insurance for direct deliveries and/or services P1 WE ARE APPLYING FOR COVER PRIOR TO DELIVERY (PRE-SHIPMENT RISK) Space for additional comments TRANSACTION INFORMATION Contract (order) (dated) (No.) Contractual value in (Contractual Currency) (Amount) We have agreed an agency fee based on the level of payment., for % of the invoice amount 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
page 3 of 5 Request for insurance for direct deliveries and/or services P1 Delivery conditions Full delivery Partial delivery Start of production Start of delivery End of delivery Hand over/commissioning Incoterms BUSINESS RELATIONSHIP OF APPLICANT WITH 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 The contractual partner met all commitments without extending the payment period and without delays Space for additional comments
page 4 of 5 Request for insurance for direct deliveries and/or services P1 CURRENT CREDITWORTHINESS INFORMATION ON CONTRACTUAL PARTNER/JOINTLY LIABLE PARTY has already been provided to OeKB Versicherung/is enclosed. will be sent in later. is t required as there is a letter of credit. will be requested by Oesterreichische Kontrollbank AG at our expense. Is there any cover for losses from ather credit insurer in the country in which the contractual partner is based? Has the requested transaction already been submitted to ather credit insurer? TEST PAYMENT WHEN ISSUING OR EXTENDING AN O1 OFFER The test payment (O1) is equal to 1 of the value of the transaction to be covered, at least EUR 100, and a maximum of EUR 800,. The test payment is due immediately upon receipt of the bill. If the customer requests an extension to the offer, the O1 offer is re-issued and the test payment re-invoiced. We will send on the following documents later Space for additional comments, particularly negative information regarding the contractual partner We hereby ackwledge 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 t 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 www.oekbversicherung.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.
page 5 of 5 Request for insurance for direct deliveries and/or services P1 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 for direct deliveries/services (P1), tied buyer credit (P3) and the purchase of receivables (P9) (2011 version) and hereby declare that we recognise these terms and conditions as part of the contract. We ackwledge that the terms and conditions and the applicable policy are binding for the legal relationship between Acredia Versicherung AG and us. SEPA Direct Debit Mandate already provided SEPA DIRECT DEBIT MANDATE Payee Creditor ID Acredia Versicherung AG, Himmelpfortgasse 29, 1010 Vienna AT30ZZZ00000008320 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 hour the Direct Debits drawn by Acredia Versicherung AG on my/our account. I/we agree to a deadline of five calendar days for advance tice 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 Email address Applicant s/payer s authorised signature