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
/ M
/ Y
Phone
Fax
Email
2- Business description
Nature of business
Manufacturer
Service
Wholesaler
Retail
Other
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?
Yes
No
Name of Carrier
Euler
Coface
EDC
Atradius
La Garantie
Chartis
Autre
Other... Please specify
Policy Expiry date - D
/ M
/ Y
I wish to cover the following markets
Cnd
US
Cnd - US
Export
I wish to receive a proposal in the following currency
Cnd
US
Are your products made specifically to measure?
Yes
No
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?
Dun&Bradstreet
Equifax
Groupe Echo
Bank reports
Financial statements
None
Other
If other, please specify
Do you use Credit applications for prospective clients?
Yes
No
Are your payment terms clearly indicated on your invoices?
Yes
No
Are your new orders received in a written manner?
Yes
No
If not, please specify
Do you currently offer special "Dating" Terms?
Yes
No
Please specify
%
Explain your "dating" terms
Do you review the account status before: Accepting an Order?
Yes
No
Order Delivery?
Yes
No
Do you presently work with an external collection agency?
Yes
No
If yes, please explain when/why?
Your Accounts receivables are calculated from?
Invoice Date
Due Date
Do you require a "Work in Progress" Endorsement?
Yes
No
Will your Bank be named as Primary beneficiary to the policy?
Yes
No
Bank name Account
BMO
National
Desjardins
CIBC
TD
HSBC
Royale
Laurentienne
Cnd.Trust
Autre
Manager
Phone Number
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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