Before Answering These Questions, Please Consult the Explanatory Notes at the End of This
Construction of Works / Equipment Cover
Before answering these questions, please consult the explanatory notes at the end of this form.
Other applications forms can be downloaded from:(Use the correct application form for your transaction)
The processing of your application by Atradius:
1.After we have received your application, we will send you an acknowledgement of
receipt.
2.If Atradius lacks financial information or has insufficientfinancial information about your
buyer, we will take steps to gather such information. We kindly request you to attach to this application any readily available (financial) information regarding your buyer.
3.If we lack financial information or have insufficient financial information of you or your guarantor for recourse obligations, we will ask you to send us such information, including annual reports with financial notes for the last three years.
4a. If the contract price exceedsEUR 10 million, we request you to complete the questions under 8. IV and to provide required annexes. In some cases, we will also request you to complete these questions if the contract price is below EUR 10 million.
4b. You do not need to answer these questions if:
- the transaction or project concerns defence or aircraft industry
- an application has been made for Dutch development assistance. If this application is denied you will still have to complete these questions.
In all other cases you will have to answer these questions.
5.As soon as we have the necessary information at our disposal (see points 2, 3, 4a and
4b), we will be able to process your application.
6.While your application is being processed, we will keep you informed regularly about
thecurrent progress.
NBAn incomplete application form may lead to unnecessary delay in the processing of the application. Provision of incorrect or incomplete information or failure, prior to the conclusion of the insurance agreement, to provide facts or information of which the Insured was at the time aware or ought to have understood was or might be relevant for the assessment of (i) the risk to be insured, (ii) the social and environmental impacts or possible impacts related to the execution of the export contract or (iii) the risk of bribery may result in, among other things, the loss of the right to indemnity under the insurance agreement or to its termination.
The insurer’s right of access to information is one of the conditions of the Insurance Agreement. If requested to do so, you are obliged, within a reasonable period of time, to allow the Dutch State (the nsurer) access to, as well as provide it with a copy of, all documents and records at your disposal and those which you can reasonably obtain, which the Insurer deems necessary to verify whether you are complying with all your obligations under the Insurance Agreement and/or whether all conditions for indemnification have been met. If the Insurer deems that the insured is uncooperative or lacking in co-operation with respect to such a request, the insurer has the right to take action. If documents or records show that you are not complying or have not complied with one or more of the obligations under the insurance agreement, you will be obliged to reimburse, on first demand, all reasonable costs incurred by the Dutch State for engaging an expert third party.
1. The Applicant
a.Name of the applicant, as listed in the Trade Register:
b.Full address (including post code):
c.Address for correspondence (P.O. Box and post code):
d.Bank giro account number and name of bank:
e.Group of which the applicant is part:
f.Name and position of applicant's contact:
Telephone: / Telefax: / Email:
- Name and address of insurance intermediary:
It is advisable to send with this form any (business) information which you have about the principal (e.g. annual reports).
2. The Principala.Name of the principal in respect of whom you are running a non-payment risk:
b.Address and country of the principal:
Telephone: / Telefax: / Email:
c.Is the principal a public body? / Yes No
d.Name and address of the principal 's bank:
e.Have you concluded transactions with this principal
previously?
(see explanatory note) / Yes No
f.Have all payments in respect of these transactions
taken place on time? / Yes No
(If not, please explain)
g.What has been your general experience of this principalin the past?
3. The Contract
(See explanatory notes)
a.Has the contract with the principal in respect of whom you are running a non-payment risk already taken effect? (See also question 10a) / Yes No
Date:
Have you already experienced unforeseen circumstances when carrying out the preparation for the work?
(See explanatory note) / Yes No
b.If the contract with the principal in respect of whom you are running a non-payment risk is to be or has been concluded by a third party, what is his name and address?
Where applicable, the information requested below should relate to the contract between the third party stated and the principal. Please give further particulars of the contract between you and that third party in an annex.
(E.g. the composition of your cost price)
c.If you are not running a non-payment risk in respect of the full amount, how large is the part in respect of which you are at risk?
% / of the contract price with the principal
d.Who are the other parties running a non-payment risk in respect of the principal?
Name: / Country: / for : / %
Name: / Country: / for : / %
Name: / Country: / for : / %
e.Description of the work to be carried out:
f.By whom is the work to be carried out:
g.Where is the work to be carried out?
Place:
Country :
h.How soon after the contract takes effect will the work be commenced?
Immediately after the contract takes effect
months after the contracttakes effect
i.How soon after the contract takes effect is the work to be completed:
months after the contract takes effect
j.The delivery is (to) an extension or modification of an existing project in the same location.
The delivery is (to) a new project
The delivery is a stand-alone transaction
k.What is the name of the project of which the transaction forms a part?
l.Please provide information on the project and the contribution of your transaction to it.
4. The Contract Price
a.What is the contract price agreed with the principal?
b. In which way will the contract price be determined?
(e.g. on the basis of certificates)
c. If the final contract price is determined on the basis of
certificates, how long is the period to which each certificate relates: / days
months
d. How soon after the end of a period must the certificate
relating to that period be submitted for approval: / days
e. How soon after the submission of a certificate must that
certificate be issued:
(Containing approval) / days
f. By whom or by what authority must the certificates be
approved:
g.Is a retention applied: / Yes No
If so, how and up to what amount:
h.On the basis of what causes may the estimated contract price be exceeded according to the contract:
(See explanatory note)
i.Give your estimate of the overrun, in total and for each cause separately:
(see explanatory note)
j.Is VAT (or a similar tax) part of the contract price? / Yes No
If yes, do you have to pay this VAT also in the case the principal fails to pay? / Yes No
If so, do you want this VAT to be covered under your policy? / Yes No
(see explanatory note)
5. Payment
a.In what instalments and on what dates must the contract price or, as the case may be,
the certificate amounts be paid?
Type of payment
(See explanatory note) / Amounts or % of the
contract price / Date of payment
b.In what currency and to what place must the agreed contract price be paid?
(If relevant, please indicate what exchange rate should be contractually applied):
Currency:
Place:
Has a legally valid conversion / transfer licence been
obtained for currency that is non-transferable, either in
whole or in part? / Yes No
If so, do you require cover for the transfer risk in narrow
terms?(see explanatory note)
If so, for what part of the contract price?
c.If amounts are to be paid in a non-transferable currency, does the contract contain a conversion clause for that purpose?
(See explanatory note)
d.Do you charge interest separately to the principal until the due date? / Yes No
e.What interest rate has been agreed?
% per year,chargeable from / (date)
f.Is interest calculated in each case on the total outstanding
amount, as a result of which the interest payments decrease? / Yes No
(If not, please explain)
g.On what dates must the interest payments be made?
h.Do you want to include interest on arrears in the insurance? (This is only possible if you have agreed upon this explicitly with your buyer in the contract)
(See explanatory note) / Yes No
If so, at what percentage per year? / %
i.Are you liable to tax in the country of the principal on the
interest paid by the principal? / Yes No
If so, at what percentage per year? / %
6. Security
a.Do you require security for the payment?
(See explanatory note) / Yes No
b.What form does the security take ?
(e.g. guarantees, letter of credit, mortgage, retention of title)
c.What parts of the contract price are covered by the above-mentioned security?
d.When must this security be provided?
e.Name and address of the parties providing the above-mentioned security:
7. Composition of cost price
a.What is the value of all deliveries not originating from the Netherlands, expressed as a percentage of the contract price? / %
1. Are there any deliveries from a single third country with a total value of more than 30% of the contract price? / YesNo
- If so, from which country?
- For what percentage? / %
2. Which part of these deliveries originates in one or more of your group companies abroad? / %
b.What is the value of the national content, expressed as a percentage of the contract price (= 100 – the answer of question a.)? (See explanatory notes)
%
c.What percentage of this contract price relates to local expenditure? (See explanatory notes)
%
d.What is the net profit?
8. Corporate Social Responsibility
I Bribery - general
(See explanatory notes)
- Are you or any party acting on your behalf aware of, or involved in the bribery of any public officials or any foreign public officials as per Articles177, 178 or 178a of the Criminal Code of the Netherlands or of private individuals as per Article 328ter of the Criminal Code of the Netherlands?
YesNo
b.During the five years prior to this application for insurance, have you, or any party acting on your behalf, been found guilty in any legal proceedings or equivalent administrative proceedings related to cases of bribery or involvement in bribery?
Yes No
c.During the five years prior to this application for insurance, have you or any party acting on your behalf been found, in any civil law or arbitration proceedings, to have engaged in or been involved in any way in bribery?
Yes No
d.During the five years prior to this application for insurance, have you, or any party acting on your behalf, reached a settlement related to bribery or involvement in bribery?
YesNo
If so, please explain:
e.Are you, or any party acting on your behalf, currently involved in any ongoing proceedings related to bribery?
Yes No
f.Are you, or anyone acting on your behalf, listed on one of the publicly available debarment lists of the following international financial institutions: World Bank Group, African Development Bank, Asian Development Bank, European Bank for Reconstruction and Development and the Inter-American Development Bank?
YesNo
g.In relation to the contract which is the subject of this application, are you aware of having bribed, or, of any party acting on your behalf or any other party involved in the project having bribed, any domestic public officials, foreign public officials or private individuals in obtaining the contract for your company?
Yes No
Is your contract as part of a sub contract related to a main contract that has been or will be signed by your buyer?
Yes No
If yes, are you aware if in obtaining the main contract bribery or an attempt to bribery has taken place or will take place?
Yes No
II Bribery - payment
(see explanatory notes)
a. Are you to pay any remuneration to a third party or parties (whether private individuals or legal entities) acting on your behalf (for example an agent or intermediary) in case you are awarded the contract and/or during your execution of the contract?
YesNo
If so, please answer the questions below; if not please proceed to Section III.
b. Please state the amount of remuneration (fixed amount or percentage of the contract value)?
c. Is this remuneration included in the contract price? / Yes No
Partially, eg:
d. Details for the party to which you are to pay remuneration:
Name of Company
Initials
Surname
Title
Address
Date of birth
Place of birth/Registered location of company
e.Who (natural person or legal entity) is the agent’s ultimate beneficial owner (UBO)? (The ultimate beneficial owner (UBO) of a legal entity is the natural person who holds at least 25 percent of the capital of the legal entity, or at least 25 percent of the voting rights at a general shareholders’ meeting, or is entitled to at least 25 percent of the equity of the legal entity.)
f.What is the nature of this remuneration? Is it for example, a performance-related commission or is it a fixed amount?
g.At which time or times is this remuneration to be paid?
h.Are you obliged to pay the remuneration in all cases, including if the buyer is in default on its payment obligations?
YesNo
i.Where is the remuneration to be paid?
j.Which services have been/are to be provided? Please be specific and describe them as clearly as possible.
k.Have you concluded an agreement for these services? / Yes No
If so, does this agreement describe the services to be provided by the counterparty? / Yes No
Is this description identical to that stated in the answer to question 8.j? / Ja Nee
If not, please provide the description of the services to be provided by the counterparty as stated in the agreement:
III Information Supply Chain
(See explanatory notes)
a.Are you familiar with the Dutch policy on supply chain management as part of the Dutch Corporate Social Responsibility (CSR) policy and the expectations for Dutch enterprises? (for more information (in Dutch): Nederlands Beleid Ketenverantwoordelijkheid)
Yes No
b.How is this being applied within your organisation? (If not yet in our possession, please provide us with a current copy of your purchase policy and/or relevant CSR procedure.)
c. Who are the most significant suppliers (no distributive trade companies) for the transaction (maximum 5)?
Name Supplier / Goods/Services / Land of origin
IV Environmental and social aspects
Before answering these questions, please read point 4a and 4b on the cover page to determine if you need to complete this section.
In case the contract price is less than EUR 10 million, but it concerns a sensitive sector, or the transaction, or project of which the transaction is part of, is located in a sensitive area we will request you to complete these questions. (See explanatory notes for question 4e and 10j).
If this is not the case, please continue with question 11.
a.Correct address, place and description of the location where the goods and/ or services will be used:
(Please provide us with a detailed map of the location.)
b.As or for what is the location currently used where the goods and/ or services will be used?
Urban
Industrial
Agricultural
Greenfield
Other, please specify:
c.To which sector will the delivery be made?
Mining, oil and gas exploration
Iron and steel
Petro-chemicals
Energy production and distribution
Land reclamation and dredging
Dams and hydro-electric equipment
Other infrastructure and civil engineering
Large-scale Agri- or Horticulture
Other sectors (e.g. industrial site), please specify:
d.What type of sensitive location could face an adverse environmental impact from the use of goods/services to be delivered or the work to be performed?
(Please mark all relevant boxes)
Delivery
location / Effect
area
Semi-arid or desert margins
Tropical or sub-tropical rainforest
River deltas, coastal areas, mangroves or coral reefs
National parks
World Heritage List/World Biosphere Reserve areas
Rare/threatened species’ habitats
Areas of very high population density
Areas of archaeological significance
Areas with indigenous peoples
Other sensitive location, please provide details:
Environmental and Social Impact Assessment
e.Does the transaction and/or project you are supplying have an analysis of its environmental and social effects and associated preventive measures, e.g. an Environmental Impact Assessment, an Environmental Impact Statement or Social Impact Assessment?
(See explanatory notes) / Yes No
(If yes, please provide a document written in English or Dutch)
f.If yes, what is the status of the impact assessment report:
- In progress
- Draft version available
- Approved by / (name organisation)
(date)
And is the impact assessment public? / Yes No
(If no, this could lead to a delay in your application)
g.Is for the transaction and/or project a management plan developed (ESMP) covering measures to mitigate potential negative environmental and social impacts?
(See explanatory note) / Yes No
(If yes, please provide a document written in English or Dutch)
h.Will there be resettlement as a consequence of the delivery to the project? / Yes No
i.As far as you know could your buyer be involved in or could the project involve:
(See explanatory note10o)
-child labour?
-compulsory labour?
-restrictions in freedom of association and collective bargaining?
-discrimination?
(If one of these questions has been answered ‘Yes’, please explain) / Yes No
Yes No
Yes No
Yes No
j.Does your transaction and/or the project apply applicable environmental and social standards and management systems (e.g. ISO 14001, VCA or OSHAS 18000)?
If yes, please specify. / Yes No
k.What standards do the techniques used meet? Please give details.
(e.g. Best Available Technique (BAT)).
Environmental and social legislation and standards
l.Which local and international environmental and social legislation and/ or standards are applicable for the transaction/ project? Please specify and add an annex if needed.
m.Who is the competent authority that verifies whether the transaction and/or project comply with the applicable legislation and/or standards?
Please specify and add an annex if needed.
n.What kind of environmental permits are or will be granted? Please provide details permit name, competent authority and date the permit was or will be granted.
If needed you may provide this information in an annex.
9. Required cover
a.Do you require partially or fully to transfer the part not
insured (own risk)? / Yes No
If so, what part and to whom?
b.Do you require a promise for the issue of Direct Guarantees to your lender for:
-bills of exchange or promissory notes to be discounted by him? (See explanatory note) / Yes No
-advances to be paid by him under a letter of credit?
(See explanatory note) / Yes No
c.Does your principal require you to provide one or more bank guarantees under the contract?
(See question 9f) / Yes No
If so, what guarantees:
d.Do you require these guarantees to be insured
as well? (Supplementary Cover)
(See explanatory note)
(Questions 9e and 9f also relate to this point). / Yes No
e.If you require Supplementary Cover, you should complete the following table.
Type of guarantee / Amount / Duration in
months / From / Movement*
Advance-payment bond
Performance bond
Maintenance bond
*Linear / Progressive / Regressive
f.Does your bank require a Counter-guarantee
for the guarantees mentioned above?
(see explanatory note) / Yes No
g.Do you also require cover for the equipment to be used abroad for this transaction (Equipment cover)?
(See explanatory note) / Yes No
If yes, what is the assessed value of the equipment that you will use for this transaction?
During which period will the equipment be used?
hDo you wish to have cover for a possible contractually agreed increase of the contract price?
(See explanatory note) / Yes No
i.If yes, how much is this increase as a percentage of the
contract price?
%
- Which cover do you require?
political only
commercial only
Atradius
David Ricardostraat 1, Amsterdam
PO Box 8982
1006 JD Amsterdam, The Netherlands
Version: September 2018
/ Phone +31 (0)20 553 92693
e-mail / IBAN NL43 ABNA 0469 8010 50
BIC ABNANL2A
Trade register Amsterdam 33226495
Registered Atradius Dutch State Business NV
VAT NL.8014.22.917.B.04