APPLICATION FORM

FOR EXPORT CREDIT INSURANCE /Buyer Credit/

Attention:

1)Before filling in this application form please read the notes on page 12.

2)You may enclose to this form financial statements of the debtor (borrower/guarantor/surety)for the last 3 years and term sheet of the transaction. Please, do not enclose to this form any credit agreement, collateral documents and any other credit documentation, it should be provided only on KUKE’s request.

3)While concluding the insurance agreement the applicant is requested to submit the following documents:

a)Applicant’s declaration on not having been engaged in bribery of the person acting as a public officer in a foreign country,

b)Exporter’s declaration on not having been engaged in bribery of the person acting as a public officer in a foreign country and commitment to fulfill financial obligations towards KUKE,

c)Exporter’s declaration concerning the domestic origin of a product or service exported within an export contract,

4)The applicant is requested to prove and document (at the time of placing a request for indemnification at the latest) to be in compliance with requirements of the Act of 7 July 1994 on Export Insurance Guaranteed by the State Treasury and with the requirements of secondary legislation adopted pursuant to this Act, in particular in connection with the domestic origin of a product or service exported within an export contract - according to the mentioned above regulations.

A.Applicant:

Full NameAddress / If the Applicant fills this form on behalf of the lender or represents a consortium of the lenders, please provide below name and address of the lender, entities forming the consortium and its leader/:

Correspondence Address:

REGON No. (only for Polish companies):

Register No.:

Person in charge:

Telephone

Fax

E-mail:

website:

  1. Data referring to credit agreement:

I. Borrower /debtor/:

Full Name & Address:

Telephone

Fax

Register Number

Debtor’s legal status: Public Private

Debtor’s rating assigned by a credit rating agency

Is the lender involved in the capital of the company of the debtor and/or has significant influence on managing it?

/If yes, please specify in the appendix/

YesNo

II. Subject of credit agreement:

Description:

III. Credit documentation

Is credit agreement concluded? YesNo

If yes, please give the number of the agreement and date of its signature

Conditions of entry into force of the credit agreement.

IV. Credit agreement value:

Total including:

  1. Principal amount /capital/

including:

  • creditfinancingexportcontract

i.e % of export contract value

  • credit for financing insurance premium

amount

  • interest capitalized during disbursement period

amount

2. Estimated interest on the principal amount including:

  • interest accrued during disbursement period

at interest rate % p.a.

payable

  • interest accrued during repayment period

at interest rate % p.a.

payable

  1. Banking fees/please specify the amount and payment date/

4. Doesthe Applicant apply / will apply for the official interest rate subsidies to the export credits within DOKE Programme?

Yes No

If yes, please give the date of a promise / submitting an application

V. Credit disbursement:

1.Principles and documentation for credit disbursement:

  1. Period of disbursement/in days/
  2. Disbursement directlyon the exporter’s account

Yes No /If no, please give additional information in the appendix/

VI. Terms of payment in credit agreement:

Credit repaymentperiod of years, payable in /frequency – monthly, quarterly, half-yearly/ capital installments and/frequency/ interestinstallments.Repayment of the first capital installmentwill be executed notlater than months from the starting point of credit.

After stipulation of the finalschedule of credit repayment but not later than before concluding an insurance agreement, specifyfinal schedule prepared as follows:

Installment / Principal amount
/capital/ / Interest / Total
/principal amount + interest/ / Payment date
1.
2.
Total

VII. Repayment collaterals: /if necessary, please describe in the appendixhow the collateral works/

Type of collateral / Value / Date of issuing /ex. before credit disbursement./ / Date of validity / Entityissuingcollateral
/name, legal status, phone, fax/
Total

Is the lender involved in the capital of the guarantor/suretyand/orhas significant influence on managing it?

YesNo

/if yes, please give detailed information/

  1. Clauses in the credit agreement (tobe filled in in case term sheet of the transaction has not been attached to the application form):

1. Denouncement of thecredit agreement is possible in the following cases:

2. Dispute resolution clauses:

3. Other significant clauses/forcemajeure, pari passu, subordination agreement, financial covenants, dividend lock-up,etc../

4.Law applicable to the credit agreement:

5. Court appointed to adjust the disputes between the parties:

  1. Data referring to export contract:

I. Full Name and Addressof exporter /or composition of exporters’ consortium/:

REGON No.

Register No.:

Person in charge:

Telephone.

Fax

E-mail:

website:

II. Full name and address of the importer:

Register No.:

III. Description of the export contract[1]:

IV. Exporter’s position in the export contract:

Main contractor Sub-contractor

Terms of settlements with the main contractor

V. Export contract value:

Amount in /currency/
1. / Paymentsmadebeforestarting point of credit /down payment/
2. / Value of export contract to be financed with buyer credit
3. / Export contract value /1+2/

Date of down payment:

VI.Exporter’s significant sub-contractors /more than 10% of export contract value/ :

No. / Sub-contractor/Specify country of origin/ / Type of goods / services / Conditions andterms of payments for sub-contractors / Value
(in the contractual currency)

VII. Contract breakdown/in the contractual currency/:

Export value
Export contract value
Value of Polish domestic elements / Value of foreign elements
No. / Third countries’ part / Local part
1. / Research, engineering works
2. / Technical supervision
3. / Deliveries of goods
4. / Assembly
5. / Construction works
6. / After sale service
7. / Transportation
8. / Cargo insurance
9. / Other insurance
10. / Other (e.g. obligatory charges)
Total
  • Please fill in the table above as detailed as possible. You can add any additional elements of the export contract (which are not listed above) in the appendix to the application form.
  • Please provide information on exchange rates, raw material purchase prices or trade offers taken into account while completing the table above.

Value of the net revenues from performance of an export contract /in an export contract currency/[2]:

Did third parties, such as agents, act on behalf of exporter in connection with the export contract?

YesNo

VIII.Expected date ofaccomplishment by exporter of all obligations arising under export contract /delivery date, commissioningdate etc./

IX.Bonds to the benefit of importer:

Type of bond / Entityissuing bond / Valuein bond currency / Validity date
From / To
bid bond
advance payment bond
performance bond
other/specify/

X.Export project status:

1. International tender: YesNo

If yes, please specify the final date for filing the offer:

Conditions proposed by foreign competitors /if known/:

2.Export contract is concluded Yes No

If yes, please specify No. of export contract& date of its signing

D.Required scope of insurance cover:

I. Public debtor, political risk

Private debtor, political risk

commercial risk

political and commercial risk

II. Required date of premium payment:

a)In a lump sum within 15 days from the date of the invoice

b)In a lump sum on the date of first disbursement /not later than 60 days from the date of the invoice/

Justification:

III.Required value of insurance cover/in currency of the credit/

Total:

including:

a)principal amount /capital/

including:

- credit financing export contract

- credit for financing insurance premium

- interest capitalized during disbursement period*

b)interest on principal amount*

c)banking fees

d)other/Please, specify/

*/If floating interest rate, please provide estimate calculationof interest

IV. Required percentage of insurance cover:

Decision on concluding the insurance agreement will be taken basing on this application as well as documents and explanations provided in connection with it in written form and in e-mail. Any information on change and alterations of the data contained in this application should be provided to KUKE without delay.

INFORMATION CLAUSE CONCERNING PERSONAL DATA PROCESSING FOR AN INDIVIDUAL EXPORT CREDIT INSURANCE AGREEMENT (BUYER’S CREDIT)

1. DATA CONTROLLER

The controller of your personal data is Korporacja Ubezpieczeń Kredytów Eksportowych Spółka Akcyjna with its registered office in Warsaw at ul. Sienna 39, 00 -121 Warszawa, hereinafter referred to as "KUKE" or the "Controller".

2. CONTACT DETAILS

In all matters concerning the processing of your personal data and your rights related thereto, you can contact the Controller at the e-mail address , by calling +48 (22) 356 83 00 or in writing at the address of the Controller's registered office indicated in point 1 above.

3. PURPOSES AND LEGAL BASIS OF DATA PROCESSING

Your data will be processed for the purpose of:

  • conclusion and performance of an individual export credit insurance agreement (buyer credit) guaranteed by the State Treasury (hereinafter referred to as the "buyer credit insurance agreement") - the legal basis for the processing is the necessity of data processing to conclude and perform a buyer credit insurance agreement,
  • pre-contractual insurance risk assessment - the legal basis for the processing is the necessity of data processing for the conclusion and performance of a buyer credit insurance agreement,
  • direct marketing of the Controller's own products and services, including profiling in order to adjust the marketing content sent - the legal basis for the processing is the necessity of processing the data in order to fulfil the Controller's legitimate interest; the Controller's legitimate interest is to provide information to customers on insurance products and other financial products offered by KUKE; in the case of consent to processing personal data for marketing purposes in the event of non-conclusion of a buyer credit insurance agreement or after termination of a buyer credit insurance agreement, such consent shall be the legal basis for processing personal data; the contact details provided and contact details obtained in the future will be used for marketing purposes,
  • possible assertion of claims or possible defence against claims related to the concluded buyer credit insurance agreement - the legal basis for the processing is the necessity of data processing to pursue the Controller's legitimate interest; the Controller's legitimate interest is the possibility of asserting claims and defending against claims resulting from the concluded buyer credit insurance agreement,
  • risk reinsurance - the legal basis for the processing is the necessity of processing the data in order to fulfil the Controller's legitimate interest; the Controller's legitimate interest is reducing the risk related to the concluded agreement,
  • fulfillment by the Controller of the obligations concerning the conduct of business on the basis of the Act on Export Insurance Guaranteed by the State Treasury of 7 July 1994 (or the Act replacing the aforementioned Act),
  • fulfilment by the Controller of the obligations concerning the storage of accounting documents regarding buyer credit insurance agreements - the legal basis for the processing is the necessity of the data processing to fulfill the legal obligation imposed on the Controller under the accounting regulations,
  • taking possible actions in relation to counteracting the payment of undue benefits or indemnities - the legal basis for processing is the necessity of processing the data in order to pursue the Controller's legitimate interest; the Controller's legitimate interest lies in the possibility of counteracting the payment of undue benefits or indemnities.

4. DATA STORAGE PERIOD

Your personal data will be stored until the statute of limitations for claims under the buyer credit insurance agreement expires or until the legal obligation to store data expires, in particular the obligation to keep accounting records relating to the buyer credit insurance agreement.

Data used for the purposes of direct marketing will not be further processed in the event of an objection.

5. DATA RECIPIENTS

Your personal data may be shared with:

a)the Export Insurance Policy Committee (Komitet Polityki Ubezpieczeń Eksportowych, "KPUE") on the basis of the Act on Export Insurance Guaranteed by the State Treasury of 7 July 1994 (or the Act replacing the aforementioned Act, regulating the terms and conditions of carrying on business under the Polish export insurance system with state support),

b)bodies and employees of state administration, on the basis of laws, resolutions and other sources of mandatory legal regulations,

c)export credit agencies from other countries for the purpose of risk reinsurance and as part of the exchange of information and obligations under the OECD Arrangement and the OECD Recommendation,

in so far as such a transfer is necessary and limited to the actual need, in connection with KUKE's activities under the Act on Export Credits Guaranteed by the State Treasury of 7 July 1994 (or the Act replacing the aforementioned Act) or in connection with legal provisions which oblige KUKE to provide certain information.

Your data may also be transferred to other entities which process personal data on the basis of an agreement concluded with the Controller, among others: IT service providers, data processors for the purpose of pursuing claims, including debt recovery, marketing agencies - where such entities process the data on the basis of an agreement with the Controller and only on the basis of instructions given by the Controller.

6. TRANSFER OF DATA OUTSIDE THE EEA

Your personal data may be transferred to recipients located in countries outside the European Economic Area.

7. RIGHTS OF THE DATA SUBJECT

You have the following rights:

a)the right of access the personal data and the right to request rectification, to object to the processing, to erase them or to limit their processing;

b)the right to withdraw your consent; the withdrawal of your consent shall not affect the lawfulness of any processing carried out on the basis of the consent before its withdrawal;

c)the right of personal data portability, i.e. the right to receive from the Controller personal data in a structured, commonly used and machine-readable format (if applicable) in order to transfer the data to another controller;

d)the right to lodge a complaint with the data protection supervisory authority where you consider that the processing of personal data relating to you is in breach of the Regulation of the European Parliament and of the Council of 27 April 2016 on the protection of individuals with regard to the processing of personal data and on the free movement of such data and repealing Directive 95/46/EC (OJ L 119, 4.5.2016, p. 1).

To exercise these rights, please contact the Controller. Contact details are given in point 2 above.

8. INFORMATION ON THE REQUIREMENT TO PROVIDE PERSONAL DATA

Providing personal data in connection with the agreement is necessary to conclude and perform a buyer credit insurance agreement and to assess the risk - without providing personal data it is not possible to conclude a buyer credit insurance agreement. The provision of personal data for marketing purposes is voluntary.

9. INFORMATION ON AUTOMATED DECISIONS, INCLUDING PROFILING

In connection with the processing of your personal data, decisions concerning you will not be made automatically (without human intervention).

I declare that I have read the above "Information concerning the processing of personal data".

Place,dateApplicant’s signature & stamp

CONSENT TO SHARING INFORMATION COVERED BY INSURANCE SECRECY CONCERNING A SPECIFIC INDIVIDUAL EXPORT CREDIT INSURANCE AGREEMENT (BUYER CREDIT) CLAUSE

Information covered by insurance secrecy in accordance with the Act on Insurance and Reinsurance Activity of 11 September 2015 concerning individual export credit insurance agreements (buyer credit) guaranteed by the State Treasury may be shared with:

a)the Export Insurance Policy Committee (Komitet Polityki Ubezpieczeń Eksportowych, "KPUE") on the basis of the Act on Export Insurance Guaranteed by the State Treasury of 7 July 1994 (or the Act replacing the aforementioned Act, regulating the terms and conditions of carrying on business under the Polish export insurance system with state support),

b)bodies and employees of state administration, on the basis of laws, resolutions and other sources of mandatory legal regulations

c)export credit agencies from other countries for the purpose of risk reinsurance and as part of the exchange of information and obligations under the OECD Arrangement and the OECD Recommendation,

in so far as such a transfer is necessary and limited to the actual need, in connection with KUKE's activities under the Act on Export Credits Guaranteed by the State Treasury of 7 July 1994 (or the Act replacing the aforementioned Act) or in connection with legal provisions which oblige KUKE to provide certain information.

I declare that I have read the above information clause relating to the provision of information covered by insurance secrecy concerning each individual export credit insurance agreement (buyer credit) guaranteed by the State Treasury and agree to the sharing of the above information.

Place,dateApplicant’s signature & stamp

On behalf of Applicant, I hereby declare that:

  1. I am aware of the penal responsibility for deeds stipulated in article 229 § 5 and article 230a of the Polish Penal Code, which fulfil the characteristics of the criminal offence of bribery of the person acting as a public officer in a foreign country,
  2. the credit agreement no...... ……...... dated ...... ………... with (the borrower) ...... ………... for financing the export contract no...... dated ...... between ...... ……...... ……...... ……………………………………………… and ...... …………………………………...... ……………………………………………...………………………………………………………... has not been/will not be concluded by the bribery of the person acting as a public officer in a foreign country or another illegal acts of similar character,
  3. I do not have any knowledge of the fact that the a.m. export contract No. …………………………….. financed within the credit agreement No. ……………………… was concluded by the bribery of the person acting as a public officer in a foreign country or another illegal acts of similar character,
  4. the Applicant was not listed on 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,
  5. the Applicant is not currently or within a five-year period preceding this declaration has not been under charge in a national court in relation to suspicion of bribery of the person acting as a public officer in a foreign country or another illegal acts of similar character, the Applicant within this period of time has not been convicted in a national court or been subject to equivalent national administrative measures for violation of laws against bribery of foreign public officials of any country,
  6. I do not have knowledge that currently or within a five-year period preceding this declaration anyone acting on behalf of the Applicant in connection with the credit agreement has been under charge in a national court in relation with suspicion of bribery of the person acting as a public officer in a foreign country or another illegal acts of similar character , or that he has been convicted in a national court or been subject to equivalent national administrative measures for violation of laws against bribery of foreign public officials of any country,
  7. upon demand of the Export Credit Insurance Corporation Joint Stock Company (KUKE S.A.) the Applicant will reveal the identity of persons acting on his behalf in connection with the a.m. credit agreement, and the amount and purpose of commissions and fees paid, or agreed to be paid, to such persons.

the Applicant is aware of the legal consequences concerning the proceedings of KUKE S.A. in relation with assessment of the Application for export credit insurance, that is refusal of cover if, KUKE S.A. undertaking enhanced due diligence, certified there is an evidencethat the a.m. export contract or credit agreement has been concluded by the bribery of the person acting as a public officer in a foreign country or another illegal acts of similar character.