Report of Premiums Payable for Financial Institutions

• Legal Form Number: EIB 92-30
• Issuer: Export-Import Bank of the United States
• Section: Export-Import Bank of the United States

REPORT OF PREMIUMS PAYABLE FOR FINANCIALINSTITUTIONSONLY

Report for Period starting: ____________ ending: ____________ IF NO PREMIUMS PAYABLE, CHECK HERE



USING SAME CODES

Coverage Type: _____________________

Policy Number:

_____________________ Insured: ____________________ Broker: ________________________________________

Obligor Type:

______________________

Transaction Type:

___________________

Contact:

__________________________ Email: ______________________ Tel: ____________________ Fax: __________________

Term:

____________________________



Premium Rate: __________________

1.(a) Name

(Foreign Obligor):__________________________________________________________________

Items marked with an asterisk(*)are requiredfields. Under

corporate ownership,

provide name of ultimate parentcompany,if

Business Address

: __________________________________________________________________________

there is a corporate owner. For number

of employeesand sales

volume, aggregateforthe companyandallit

s affiliates2,

including

City:

________________________ State: _____ Zip Code: _________ Country: ______________________

corporate owners and subsidiaries. See reverse for instructions.

1.(b) *Exporter Legal Name: _____________________________________________________ Tradestyle: ________________________________________________________

*Business Address: ____________________________________________________________

*City: _______________________________________________________ *State: _________ *Zip + 4: ____________________ Country: _____________________________

1.(c) *Importer Legal Name: _____________________________________________________ Tradestyle: ________________________________________________________

*Business Address: ____________________________________________________________

*City: _______________________________________________________ *State: _________ *Zip + 4: ____________________ Country: _____________________________

2. Coverage Type: ________________________________ 3. ObligorType: ________________________________ 4. TransactionType: _________________________________

5. Term: ______________ 6. Policy Endorsement # of Obligor: _____________________________ Content Methodology: _____________________ %of US Content ________

Description of Local Cost ____________________________________________________ Local Cost Provider ___________________ Local Cost NAICS Code _________________

Local Cost($) ____________________ 7. Amount _______________________ 8. Premium RatePer $100 ______________________9. Premium DUE ____________________

SBA SMALL BUSINESS : yes no SBA ALTERNATIVE SMALL BUSINESS: yes no unknown Products Exported______________________________________________

*Does the exporter have any affiliates2? __ *Total Number of Employees: _______ *Corporate Ownership: ______________________ *Annual Sales Volume: ______________

*Minority-______________ *Women-______________ *Veteran-_____________ or *Disability-Owned business ______________

American Indian or Alaska Native  Asian  Black or African American  Native Hawaiian or Pacific Islander  White  Other  Ethnicity _____________________

10.REPORT TOTALS _____________________

REPORT ADDITIONAL PREMIUMS STARTING ON PAGE 4

EIB 92-30 (Rev. 9/2022) |OMB 3048-0021 | Expires 10/31/2025