Insurance Form Questionnaire

Heading
Mike Dodson

Email: Mike.dodson@atradius.comTel: 317-588-1070
Short Form Questionnaire

For informational purposes only
Company Name/ DBA *
Additional name insured ?
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Role*
Name*

First NameLast Name
Phone Number*
Mobile Number
E-mail*
example@example.com
Are you currently insured ?

YesNo
Who is your current insurer ?
What products/service do you sell ? *
To what market sector do you sell ? *
What are your standard Terms of Payment *
Do you agree with longer terms (If yes, show the maximum terms)*
Projected "Insured" Sales: (Please exclude any inter-company sales and letter of credit, or otherwise secured, sales from this figure)*
Total domestic sales:
Total export sales:

Breakdown of Sales per Country

Insurable Sales

	Current Year to date	Calendar Year 2016	Calendar Year 2015	Calendar Year 2014
Period (indicate if different than the above headings)
Insurable Sales
Total Value of all Sales
Largest Bad Debt
Number of Losses

Buyer Breakdown (Please provide current AR Aging Summary)

Type a question

Accounts receivable balances at:

DSO (Days Sales Outstanding
Attach a file of your top 20 buyers, including their legal name, complete address along with requested credit limit. This limit should be the maximum exposure you have to this customer at any one time.

Cancelof
The maximum level of coverage we can provide is dependent upon the quality of the financial information we receive from your customers. Our experience shows that using suppliers names when calling companies for financials greatly improves the chances to obtain updated information. Do you authorize Atradius Trade Credit Insurance to use your company name when contacting your customers?*

YesNo
Applicant Signature:*
Date: *
Should be Empty:

Heading