Report of Premiums Payable for Financial Institutions

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

REPORT OF PREMIUMS PAYABLE FOR FINANCIALINSTITUTIONSONLY

Report for Period starting: ____________ ending: ____________ IF NO P REMIUMS PAYABLE, CHECK HER E



US ING SAME CODES

Coverage Type: _____________________

Policy Number:

_____________________ Insured: ____________________ Broker: ________________________________________

Oblig or Type:

______________________

Trans action Type :

___________________

Contac t:

__________________________ Email: ______________________ Tel: ____________________ Fax: __________________

Term:

____________________________



Premium Rate: __________________

1. (a) Name

(Foreign Obligor):__________________________________________________________________

Ite ms m arked w ith an asteris k (*) are requ ired fiel ds. Und er

corp orate owne rship,

prov ide nam e of ulti mate pa rent co mpany, if

Business Address

: __________________________________________________________________________

the re is a corp orate owner. Fo r num ber

of e mployees an d sales

volume, ag gregatefor the company and all it

s affiliates2,

including

City :

________________________ State: _____ Zip Code: _________ Country: ______________________

corp orate owne rs and s ubsidiari es. See re vers e for ins tructio ns.

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

*Business Address: ____________________________________________________________

*City: ____________________________________________________ ___ *S tate: _ ________ *Zip + 4: ____________________ Country: _____________________________

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

*Business Addr ess: ____________________________________________________________

*City: ____________________________________________________ ___ *S tate: _ ________ *Zip + 4: ____________________ Country: _____________________________

2. Co vera ge Type: ________________________________ 3. ObligorTy pe: ____________________ ____________ 4. Transac tion Type: _________________________________

5. Ter m: ______________ 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. Pr emium Rate Per $100 ______________________ 9. Premium DUE ____________________

SBA S MALL BUSINESS : yes no SBA ALTERNA TIVE SMALL BUSINE SS: yes no unknown Products Expor ted_ ____ _________________________________________

*Do es the exp orter hav e any affiliates2? __ *Total Number of Empl oyees: _______ *Corporate Ownership: ______________________ *Annual Sales Volume: ______________

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

Ameri can I ndian or Alaska Nati ve  Asian  Blac k or African Americ an  Native Hawaiian or Pacif ic Isl ander  White  Oth er  Ethnic ity ___________________ __

10.REPOR T TOTAL S _____________________

REPOR T ADDITIO NAL P REMIUMS STARTING ON PA GE 4

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