Short Term Single Buyer Insurance Application

• Legal Form Number: EIB92-64
• Issuer: Export-Import Bank of the United States
• Subject Matter: Insurance
• Section: Export-Import Bank of the United States

OMB No. 3048-0018

Expires 02/28/2025

APPLICATION FOR EXPORTER SHORT-TERM,

SINGLE-BUYER INSURANCE

This application is to be completed by an Exporter (or a Broker acting on its behalf) in order to obtain a short-term

insurance policy covering sales to a single foreign Buyer. Repayment terms can be up to 360 days.

An online version of this application is available on EXIM’s web site. EXIM encourages customers to apply on line, as

it will facilitate our review and allow customers a faster response time. Additional information on how to apply for

EXIM insurance can be found on EXIM’s web www.exim.gov IMPORTANT: The Guarantor, Buyer and End User must

be foreign entities in countries for which EXIM is able to provide support, see EXIM's Country Limitation Schedule.

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

Emailed PDF and faxed applications. EXIM will not require the originals of these applications to be mailed. The

application must be PDF scans of original application and all required documents. (Fax number 202.565.3380, Email

exim.applications@exim.gov)

APPLICATION FORM

Under corporate ownership, provide name of ultimate parent company, if there is a corporate owner. For

number of employees and sales volume, aggregate the information for the company and all its affiliates1

,

including corporate owners and subsidiaries.

Applicant/Exporter Legal Name: DUNS#

Trade ts y: le

Business Address:

City: State: Zip+4: Country:

If there is Corporate Ownership of Applicant please state:

Does the Applicant have any affiliates: Yes  No Applicants Primary Industry NAICS2:

Total Number of Employees (for Applicant and any affiliated companies):

Annual Sales Volume (for applicant and any affiliated companies):

Position Title:

Contact Person:

Email:

Phone: Fax (optional)

Woman-owned business: Yes No Decline to answer

Minority-owned business: Yes No Decline to answer

Race (One or more boxes may be selected.):

American Indian or Alaska Native Asian Black or African American

Native Hawaiian or Pacific Islander White Other

Ethnicity: Hispanic or Latino Not Hispanic or Latino

Veteran-owned business: Yes No Decline to answer

Disability-owned business: Yes No Decline to answer

Broker (if applicable):

Name of Brokerage: Contact Person:

E-mail: _______________________________________Phone number: ___________________Fax: _____________________________

1 Affiliations exist when one individual or entity controls or has the power to control another or when a third party or parties control or have the

power to control both. Factors such as common ownership, common management, previous relationships with or ties to another entity, and

contractual relationships may cause affiliation. The complete definition of affiliation is found at 13 C.F.R.§ 121.103.

2 A company’s Primary Industry NAICS codes is the NAICS that accounts for the largest share of sales for the most recently com pleted fiscal year.

The full definition of “primary industry” is set forth at 13C.F.R. § 121.107.

EIB 92-64 (Rev. 7/2021) Page 1 of 8