ccd assurance
francais
telephone courriel
APPLICATION FORM
1- Corporate Information
Company legal entity Other entities to cover
Address City Province
Postal Code
Policy Contact Title
Company in business since Fiscal Year End - D
Phone Fax Email


2- Business description
Nature of business Other... Please specify
Products and/or Services to cover
Approximate Number of active accounts:   Cnd US Other
Estimated Outstanding A/R $ DSO (Average Number Days of Sales Outstanding)
Do you currently have a trade credit insurance policy?
Name of Carrier Other... Please specify Policy Expiry date - D
I wish to cover the following markets
Cnd US Cnd - US Export
I wish to receive a proposal in the following currency
Are your products made ​​specifically to measure?
Name of your accounting Firm


3- Sales & Bad Debt History
  YEAR 1 YEAR 2 YEAR 3
CANADA SALES ($) Date ($) Date ($) Date
BAD DEBT- TOTAL ($) Date ($) Date ($) Date
BAD DEBT- NUMBER ($) Date ($) Date ($) Date
US SALES ($) Date ($) Date ($) Date
BAD DEBT- TOTAL ($) Date ($) Date ($) Date
BAD DEBT- NUMBER ($) Date ($) Date ($) Date
EXPORT SALES ($) Date ($) Date ($) Date
BAD DEBT- TOTAL ($) Date ($) Date ($) Date
BAD DEBT- NUMBER ($) Date ($) Date ($) Date


4- Projected Sales by Country for the Next 12 Months
  COUNTRY MAXIMUM TERMS OF SALES TOTAL SALES ($)
1
2
3
4
5


5- 10 Key Buyers Information
Concentration:
Our most important client represents % of our total sales
Our 3 most important clients represent % of our total sales
  LEGAL NAME ADDRESS TEL NUMBER REQUESTED COVERAGE ($)
1
2
3
4
5
6
7
8
9
10


6- Your Internal Credit Management Process
Persons handling your internal Credit Process:
Name Title
Name Title
Which of the following resources do you use?
If other, please specify
Do you use Credit applications for prospective clients?
Are your payment terms clearly indicated on your invoices?
Are your new orders received in a written manner?
If not, please specify
Do you currently offer special "Dating" Terms? Please specify %
Explain your "dating" terms

Do you review the account status before: Accepting an Order? Order Delivery?

Do you presently work with an external collection agency?
  If yes, please explain when/why?
Your Accounts receivables are calculated from?
Do you require a "Work in Progress" Endorsement?
Will your Bank be named as Primary beneficiary to the policy?
Bank name Account Manager


7- Provincial tax Declaration on insurance products
Provincial taxes on insurance premiums will be calculated based on the percentage of sales to customers located in provinces mentioned below; provided that you operate in these provinces.

Is considered "operating" a business in those provinces when:
- You have a commercial establishment domiciled in the respective province. OR
- You have a designated representative who carries out sales to companies within that province.
We deal with customers in Quebec %
We deal with customers from Ontario %
We deal with customers in Manitoba %



As part of this application for insurance and any trade credit insurance policy that may result, we declare that the information contained in this application is correct and that no relevant information has been omitted. Any person who submits a proposal or a claim containing a false or misleading statement in order to commit fraud or knowing that it facilitates a fraud against an insurer or any other person may be guilty of fraud to insurance. The proposal and said policy, as well as their terms and conditions represent the entire agreement between the undersigned and the insurer, notwithstanding any statement, promise, verbal or written agreement to the contrary effect from any agent of any insurer carrier, a notice delivered to such agent or any other person, or due to their knowledge. It is also understood that this proposal, given that it contains or what is omitted, was drafted, completed and written by the applicant or his authorized representative. If changes occur in the information contained in this form, between its presentation and the issuance of the insurance policy arising, we will immediately notify the Dowd Brokerage Firm. Having completed and submitted this proposal does not warrant the issuance of an insurance contract.

I hereby agree to retain the services of the Dowd Brokerage Firm as our commercial damage insurance broker and understand his mandate to be a complete market analysis with available insurers for our trade credit insurance needs and related services. This mandate will be considered "in force" from the present signing and will remain in effect until one of the parties terminate this agreement by notice in writing.

It is also understood that the Dowd Brokerage Firm can obtain confidential information in the exercise of its functions and should not disclose this information or give access to anyone, except for information which must be provided to underwriters for analysis.

Name Title Date

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