Short Term Bank Letter of Credit Insurance Application

• Legal Form Number: EIB92-34
• Issuer: Export-Import Bank of the United States
• Subject Matter: Insurance
• Section: Export-Import Bank of the United States

OMB No. 3048-0009

Expires 10/31/2024

EIB92-34

Revised 04/2021

App. Number (Ex-Im Bank Use Only)

APPLICATION

FOR SHORT-TERM LETTER OF CREDIT

EXPORT CREDIT INSURANCE POLICY

This application is to be completed by a financial institution (or a broker acting on its behalf) in order to obtain a short-term letter

of credit insurance policy. An online version of this application is available on Ex-Im Bank’s web site. EXIM Bank encourages

customers to apply online, as it will facilitate our review and allow customers a faster response time. Additional information on

how to apply for EXIM Bank insurance can be found at EXIM’s web site http://www.exim.gov.

Send this completed application to EXIM Bank, 811 Vermont Ave NW, Washington, D.C. 20571. EXIM Bank will also accept e-

mailed pdf and faxed applications. EXIM Bank will not require the originals of these applications to be mailed. The application

must be PDF scans of original applications and all required attachments. (Fax number 202.565.3675, e-mail

exim.applications@exim.gov)

Applicant Name:

Nine-digit zip code:

E-mail:

Fax #:

Phone #:

Country:

City:

Street Address:

Position Title:

Contact Person:

State/Province:

Name of Broker:

Ex-Im Bank Broker #:

E-mail:

Fax #:

Phone #:

Contact Person:

Please provide the following information from the applicant’s most recent audited financial statements.

Statement period (fiscal or interim): Are the financial statements combined or consolidated?

Financial Statement Dates:

Auditor:

Equity:

Net Loans:

Opinion:

Total Assets

Net Income:

Broker: If Applicable

APPLICANT

No

Yes

Does the applicant have a market rating?

Duns #:

NAICS code:

Website:

If yes, indicate the name of the rating agency, rating, type of rating, outlook, and the date of the rating.

Woman Owned?

Minority Owned?

Veteran Owned?

Does the Applicant have any affiliates?

Is there corporate ownership?

Yes No Decline to Answer

Yes No Decline to Answer

Yes No Decline to Answer

Yes No Decline to Answer

Yes No Decline to Answer

Name of the ultimate parent company:

Annual Revenues:

# of Employees:

Do the Statement Dates above apply to both the Balance Sheet and Income Statement? No

Yes

Did auditor provide a qualifying opinion? No

Yes

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