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Mike Dodson
Email: Mike.dodson@atradius.com
Tel: 317-588-1070
Short Form Questionnaire
For informational purposes only
Company Name/ DBA
*
Additional name insured ?
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Idaho
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Maine
Maryland
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New York
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Role
*
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Mobile Number
Format: (000) 000-0000.
E-mail
*
example@example.com
Are you currently insured ?
Yes
No
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
Rows
Country
Annual Sales
No. of Buyers
1.
2.
3.
4.
5.
6.
7.
Insurable Sales
Rows
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)
Rows
Range Credit Limits
# of Customers
Over $250k
$100-$250k
$50k-$100k
$25k-50k
$10-$25k
Under $10k
Debtor Aging as of:
Type a question
Rows
Total Amount Outstanding
Current - Not yet due
1-30 days
31-60 days
61-90 days
Over 90 days
Accounts receivable balances at:
Rows
Amount
Quarter Ending 3/31
Quarter Ending 6/30
Quarter Ending 9/30
Quarter Ending 12/31
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.
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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?
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