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Application for a Business Credit Insurance Policy
All information provided will be held in strict confidence.

INSURANCE COVERAGE REQUESTED
Domestic (U.S. and Canada Only) Multi-Markets (Domestic and Export)

Application Information
Company Legal Name:
Company President Name:
Company Address:
City:      State/Province:      Zip/Postal Code:
Policy Contact Name:       Policy Contact Title:
Phone:      Fax:      E-mail:
Other entities/tradestyles to be covered:

Business Description
Your business : Manufacturer    Wholesaler    Retail    Other
Products and/or services to be covered:
Does your company sell to countries other than the U.S. and Canada? Yes    No
Is your most recent financial statement attached: Yes    No

Accounts Receivable Summary
Domestic Export*
Total number of active accounts        
Total amount of sales $ $
Estimated total outstanding receivables in peak months $ $
Provide ending A/R and dates for the four prior quarters
1Q (date ) $ $
2Q (date ) $ $
3Q (date ) $ $
4Q (date ) $ $

Terms of Sale
Normal open account terms of sale Days Days
Days sales outstanding (DSO) Days Days
Percentage of sales under normal terms % %
Longest terms of sale (include dating) Days Days
Percentage of sales under longest terms % %
Percentage of sales using letter of credit % %
Types of documentary collections
Terms of documentary collections Days Days
Percentage of sales using documentary collections % %

Sales and Loss History
DOMESTIC
Gross profit margin 00.00%             Forecasted net domestic sales (next 12 months) $
Current YTD Three most recent full year's results
(In thousands)		 Worst loss year over last five
Date:
   		Date:
   		Date:
   		Date:
   		Date:
  
Net sales $ $ $ $ $
Bad debts $ $ $ $ $
Number of bad debt write-offs # # # # #
Largest single loss: $ $ $ $ $
   Name of company
   City/State or Province
Second largest single loss $ $ $ $ $
   Name of company
   City/State or Province


EXPORT*
Number of years exporting:
Gross profit margin 00.00%             Forecasted net domestic sales (next 12 months) $
Current YTD Three most recent full year's results
(In thousands)		 Worst loss year over last five
Date:
   		Date:
   		Date:
   		Date:
   		Date:
  
Net sales $ $ $ $ $
Bad debts $ $ $ $ $
Number of bad debt write-offs # # # # #
Largest single loss: $ $ $ $ $
   Name of company
   City/State or Province
Second largest single loss $ $ $ $ $
   Name of company
   City/State or Province
* If your company does not export outside the U.S. and Canada, you do not need to fill out the export sections.

Distribution of Export Sales
List top countries by sales Terms of payment              Sales
1. $
2. $
3. $
4. $
5. $
6. $
7. $
8. $

Credit Management Process
Do you have formal written credit procedures? Yes    No
Who in your company manages the credit management process and who assists in that effort?
Name:       Title:       Full Time    Part-time
Name:       Title:       Full Time    Part-time
Do you establish credit limits?
       If yes, on what basis is a specific limit established?
       Mercantile Report (agency:)          Bank Reference:
       Financial Statement          Other sources (e.g. trading experience)
At what credit limit are financial statements normally required? $
Are regular personal visits made to see client? Yes, by whom?  
No
How often is credit and/or financial information updated?
How often is credit limit reviewed and on what basis?
What information do you use when reviewing the credit limit?
Do you use security instruments in establishing credit limits? Yes, what kind?
No
Do you refer to the status of the account before authorizing? Yes    No
      Acceptance of order: Yes    No Dispatch/Delivery Yes    No
Are orders received in writing? Yes    No
      Approximate time from order acceptance to delivery?
Under what circumstances have you stopped shipping an account (e.g., past due condition)? Please provide details.
Do you currently insure or factor your receivables? Yes, by whom?
No
Do you have formal collections procedures? Yes    No
      If yes, what in-house resources do you use?
Under what circumstances do you place accounts for collections with outside agencies?
How do you manage your international collections?

Past Due Table
List all customers on which coverage is being requested with undisputed amounts more than 60 days past due under original terms of sale, or that you have reason to believe will become 60 days past due. If there are none, please indicate by writtin "none"
Customer
Name/Country		 Shipment dates Account balance (in thousands) Amount 60 days + Orig. terms of sale(net) Reason for past due
1. $ $
2. $ $
3. $ $
4. $ $
5. $ $
6. $ $
7. $ $
8. $ $
We will rely on the representations provided by you in, and in connection with, this application when making decisions regarding any policy we may issue. This application, the policy, and the declarations shall constitute the entire insurance agreement between you and Fidelity&Marine. No loss which occurs prior to the payment of the premium will be covered even if the policy has been delivered. No sales representative is authorized to delete, modify, or waive any policy provisions, either verbally or in writing.

For your protection, State Law (in many states) requires the following to appear on this form:
"Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any material false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and punishable by law." (New York statues further state that fraudulent acts "shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.")

Our efforts to provide maximum coverage on your customers is dependent on our ability to obtain financial infomation. Fidelity&Marine may need to contact your customers to request the information needed for these coverage decisions. Do we have your permission to use your company name when contacting your customers?
Yes    No
Name/Title:        Submitted by:
Name of organization:        Location:

       




Mailing Address: P.O. Box 284, 15476 NW 76 Ct - Miami Lakes, FL 33016
Tel: (305) 556-1488  Fax: (305) 556-3680