Political Risk Form

Political Risk Form
Personal Details
Name of Company
Contact person

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Your role in this transaction
Principal's Authority (applicable for brokers/ intermediaries - a letter of appointment from the potential insured is required): *
Financial Services Commission
Transaction for which insurance cover is requested (state whether it is an equity investment; shareholder loan; commercial loan; loan guarantee; mobile asset; trade in goods/services on open account, leasing etc.): the potential insured is required): *
Insurance Details
Amount and Currency of Cover Requested:*
Tenor (indicate period for which cover is requested in months/years):
Expected Policy Start Date

MonthDayYear
Date
Insurance Type
Tick below the type(s) of risk for which insurance cover is requested:
Credit Risks
Political Risks
Transactions/Investment Parameters

Details on Party to be insured
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Form

Natural personPrivateSub-sovereignPublic ListedParastatalOther
Nature of Business
Number of Employees

1-2021-5051-100More than 100
Details of Risk Counterparty/Project Enterprise
Name
Country
Legal Form

Natural personPrivateSub-sovereignPublic ListedParastatalOther
Transaction/Project Details
Insured Transaction/Project (Brief description)
Value and Currency of Transaction/Project
Transaction Project Type

Supplier CreditBuyer CreditSupply AgreementLeases AgreementOther
Contract Terms & Conditions (if applicable, please provide details of contract/draft loan term sheet):
Terms and Method of Payment:
Specific Comments (if necessary, please provide additional comments not captured in this enquiry form):
DOCUMENTS TO BE ENCLOSED:
- LAST FINANCIALS
- INCORPORATION CERTIFICATE
- BUSINESS REGISTRATION CARD
The information provided in this request form does not constitute a commitment towards the credit/political risk insurer. You confirm that the information provided in this form is true and accurate. Should this information change, you agree to immediately inform the service provider. Contractual agreements: By signing this proposal form, you are assigning an exclusive mandate to Risk Shield Ltd to discuss with any registered political/credit insurer (domestic or international) on your behalf. The present proposal form (mandate) automatically supersedes any previous mandate (with any broker or any direct negotiation previously engaged except if agreed by us through a written notice) and this exclusivity has a validity period of 6 months as from date of signature of this proposal form. In case you choose to implement political/credit insurance solution and go ahead to sign a credit insurance contract before the end of this time frame, Risk Shield Ltd will automatically be your broker officially for the lifetime of the contract for the first year and future renewals unless mutually agreed by both parties through a written agreement.
Should be Empty:

Political Risk Form

Personal Details

Insurance Details

Insurance Type

Transactions/Investment Parameters

Details of Risk Counterparty/Project Enterprise

Transaction/Project Details