Short Term Single Buyer Insurance Application Prepare and file this application ONLINE! at EXIM Online

• Legal Form Number: EIB92-64
• Issuer: Export-Import Bank of the United States
• 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 becompleted 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.govIMPORTANT: 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 ofthese applications to be mailed. The

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

exim.applications@exim.gov)

APPLICATION FORM

Under corporate ownership, provide nameof ultimate parentcompany, if there is a corporate owner. For

number of employees and salesvolume, aggregate the information for the companyand all its affiliates1

,

including corporate owners and subsidiaries.

Applicant/Exporter Legal Name: DUNS#

Trade tsy:le

Business Address:

City: State: Zip+4:Country:

If there is Corporate Ownership of Applicant please state:

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

Total Number of Employees (for Applicant and anyaffiliated companies):

Annual Sales Volume (for applicant andany affiliated companies):

Position Title:

Contact Person:

Email:

Phone:Fax (optional)

Woman-owned business:YesNoDecline toanswer

Minority-owned business:YesNoDecline toanswer

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

American Indian or Alaska Native AsianBlack or African American

Native Hawaiian or Pacific IslanderWhiteOther

Ethnicity:Hispanic or LatinoNot HispanicorLatino

Veteran-owned business:YesNoDecline toanswer

Disability-owned business:YesNoDecline toanswer

Broker (if applicable):

NameofBrokerage:ContactPerson:

E-mail: _______________________________________Phonenumber: ___________________Fax: _____________________________

1 Affiliationsexist when one individual orentity controlsor hasthe power tocontrol another or when a third party orparties control orhave the

power tocontrol both.Factorssuch ascommon ownership, common management, previousrelationshipswith or tiestoanother entity, and

contractual relationshipsmay cause affiliation.The complete definitionofaffiliationisfound at 13 C.F.R.§ 121.103.

2 A company’s Primary Industry NAICS codes istheNAICS thataccounts for thelargest shareof sales for themost recentlycompleted fiscal year.

Thefull definitionof “primary industry” is set forth at 13C.F.R. § 121.107.

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