**EXPORT-IMPORT BANK OF THE UNITED STATES (EX-IM BANK)**

# BROKER REGISTRATION FORM

Insurance brokers and agents are eligible for commission payments under
Ex-Im Bank export credit insurance policies if the broker or agent is
registered with Ex-Im Bank and is appointed as broker-of-record by the
policyholder either by designation on an insurance policy application or
by separate letter.

Name of
Brokerage\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Contact:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Title:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
PO BOX:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_State:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_Zip:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Phone: (\_\_\_\_\_)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Fax:
(\_\_\_\_\_)\_\_\_\_\_\_\_\_\_\_\_\_\_\_
E-Mail:\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Tax ID #:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ DUNS
#:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ No. of Employees:\_\_\_\_\_\_

Indicate (Not Required) if owned by a woman or an ethnic minority,
describe \_\_\_\_\_\_\_\_\_\_\_\_\_

Other lines of brokered
Insurance:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

Do you have other offices you wish to register (to be eligible for
commissions)? □ No □Yes

If \"Yes\", please list firm\'s name, address, telephone number, fax
number and contact person on a separate sheet.

A list of registered insurance brokers is available on the Ex-Im Bank
Internet Website and unbrokered applicants are referred to the list.
Please indicate here if you **DO NOT** wish your name released.

1.  You are required to review, understand and **sign** the attached
    "Standards of Service".

> 2\. Attach a copy of a current, valid insurance brokerage **license**
> indicating issuance and/or expiry date(s).

3\. Forward the attached "Authorization for Automated Deposits" form.

**The Broker** (it) **CERTIFIES and ACKNOWLEDGES to the Ex-Im Bank**
(the Bank) that:

1.  a\) neither it nor its principals has been within the past 3 years:

> 1\) debarred, suspended or declared ineligible from participating in
> or voluntarily excluded from participation in a Covered Transaction or

2\) formally proposed for debarment, with a final determination still
pending;

> 3\) indicted, convicted or had a civil judgement rendered against them
> for any of the offenses listed in the **Government Wide Nonprocurement
> Debarment and Suspension Regulations; Common Rule** which defines
> Covered Transaction.
>
> 4\) It certifies that it is **not delinquent** on any amounts due and
> owing to the U.S. Government, its agencies or instrumentalities as of
> the date of this application. **OR**
>
> b\) It has received a **written** statement of exception from the Bank
> and **attached** it to this certification, permitting participation in
> the transaction despite an inability to make certifications 1 through
> 4.
>
> It further certifies that it has not and will not knowingly enter into
> any agreements in connection with the transaction with any individual
> or entity that has been subject to 1, 2 or 3 above.

EIB-92-79 (02/04) Page 1 of 5

2\. it will complete and submit **Form-LLL**, Disclosure Form to Report
Lobbying if, to the best of its knowledge and belief, **any funds have
been paid or will be paid** to any person in connection with this
application for influencing or attempting to influence:

a\) an officer or employee of any U.S. Government agency, or

b\) a Member of Congress or a Member's employee, or

c\) an officer or employee of Congress.

3\. corrupt payments made in connection with Bank supported transactions
may be a violation of the **Foreign Corrupt Practices Act of 1977** (15
USC 78dd-1, et. seq.) which provides for civil and criminal penalties
against individuals who directly or indirectly make or facilitate
corrupt payments to foreign officials to obtain or keep business.

4\. a) the information being requested is done so under authority of the
**Export-Import Bank Act of 1945** (12 USC 635 et.seq.);

b\) providing the information is mandatory. **Failure to do so** may
result in the Bank being unable to

determine eligibility for the Insurance Program. The information
provided will be reviewed to determine if the

broker meets the Bank's legislative requirements under the program

c\) the Bank may not require the information and applicants are not
required to respond unless a currently valid OMB

control number is displayed on this form (see upper right of each page);

d\) the information provided will be held confidential subject to the
**Freedom of Information Act** (5 USC

552\) and the **Privacy Act of 1974** (5 USC 552a), except as required
to be disclosed under applicable laws;

e\) the Bank shall have a right to transfer to another U.S. Government
authority any financial records included in this

certification or other correspondence as necessary to process, service,
foreclose or collect on an insured debt.

No other transfer of records to private parties or another U.S.
Government authority will be authorized except as permitted under the
**Right of Financial Privacy Act of 1978** (12 USC 3401).

f\) the **public burden** reporting for this collection of information
is estimated to average 2 hours per response, including

reviewing instructions, searching data sources, gathering information,
completing, and reviewing the application.

Send **comments** regarding the burden estimate, including suggestions
for reducing it, to Office of Management and

Budget, Paperwork Reduction Project, Washington, D.C. 20503.

5\. the representations made and the facts stated by it in these
certifications and its attachments **are true, to the best**

**of its knowledge and belief, and it has not misrepresented or omitted
any material facts**. It further

understands that these certifications are subject to the penalties for
fraud against the U.S. Government (18 USC

1001).

Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Print
Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Title: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Send this application to Attn: Business Development , Ex-Im Bank,**

**811 Vermont Avenue, NW, Washington, D.C. 20571 or an Ex-Im Regional
Office.**

**The Ex-Im Bank website is [http://www.exim.gov]{.underline}**

EIB -- 92-79 (02/04) Page 2 of 5

# INSURANCE BROKERS

# STANDARDS OF SERVICE

1\. To act in a professional, reasonable, prudent and forthright manner
in all dealings with your client and Ex-Im

Bank.

2\. To make certain that your clients understand that you are neither an
Official Representative.

3\. To stay knowledgeable about not only Ex-Im Bank export credit
insurance but alternatives, including other Ex-

Im Bank programs, other U.S. government programs, and private sector
products as well, in order to provide the

best options to your clients.

4\. To educate your clients about Ex-Im Bank\'s Insurance Program and
policies, its\' benefits and proper usage.

5\. To serve as your clients\' primary contact for any questions
concerning the policies and the servicing of a policy.

6\. To review all applications and issuances of policies, actions under
policies, renewals of policies and credit limits,

and claims, for timeliness, completeness, accuracy and reasonableness.

7\. To review correspondence from Ex-Im Bank with your clients,
including quotes and credit limits, to assist them

in understanding the coverage and their responsibilities.

8\. To assist your clients to comply with the Agreements of the Insured
including shipment reports, premium

payment and reports of overdue accounts, and to advise Ex-Im Bank of any
potential claims.

9\. To report policy cancellations and submit a premium reconciliation
to Ex-Im Bank.

I have read the above standards, agree that they are reasonable, and
will comply with these standards.

I understand and agree that substantial failure by me to comply with
these standards could result in withdrawal from

the list of registered insurance brokers published by Ex-Im Bank and
cancellation of eligibility for commission

payments under Ex-Im Bank export credit insurance policies.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name of Brokerage Signature of Broker Date

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Print Name

EIB-92-79 (02/04) Page 3 of 5

**EXPORT-IMPORT BANK OF THE UNITED STATES**

**AUTHORIZATION FOR AUTOMATED DEPOSITS**

**(ACH CREDITS)**

I hereby authorize the Export-Import Bank of the United States
hereinafter called Ex-Im Bank, to initiate credit entries to my **\[ \]
CHECKING \[ \] SAVINGS account *(check one) ***indicated below and the
depository named below, hereinafter called DEPOSITORY, to credit the
same to such account.

> DEPOSITORY NAME
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> BRANCH
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

CITY \_\_\_\_\_\_\_\_\_\_\_\_\_ STATE\_\_\_\_\_\_\_\_\_\_\_\_\_
ZIP\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

TRANSIT/ABA NUMBER: □□□□-□□□□ - □

ACCOUNT NUMBER:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

This authority is to remain in full force and effect until Ex-Im Bank
has received written notification from me of its termination in such
time and in such manner as to afford Ex-Im Bank a reasonable opportunity
to act on it.

BROKER NAME
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> *(please print)*

BROKER
NO.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

SIGNATURE\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ DATE
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**PLEASE ATTACH A VOIDED CHECK FOR THE ACCOUNT NAMED ABOVE**

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

***FOR EX-IM BANK USE ONLY***

DATE RECEIVED

PROCESSED BY

**Return to:** Export-Import Bank of the United States

Director - Broker Relations

811 Vermont Avenue, N.W.

Washington, DC 20571

EIB-92-79 (02/04) Page 4 of 5

**EXPORT-IMPORT BANK OF THE UNITED STATES (EX-IM BANK)**

**BROKER COMMISSION SCHEDULE**

**FOR EXPORT CREDIT INSURANCE POLICIES**

Effective: October 1, 1994

**BROKER ELIGIBILITY**

Insurance brokers and agents are eligible for commission payments under
Ex-Im Bank export credit insurance policies if the broker

or agent is **registered** with Ex-Im Bank and is **appointed** as
broker-of-record by the policyholder. The policyholder reserves the

right to appoint, delete or change the broker of record at any time.
Brokers of record are entitled to any commissions due on

premiums paid prior to a change in the broker of record.

**COMMISSION RATES**

Commission rates paid by Ex-Im Bank are based on the type of
policyholder to which the policy is issued, as shown in the chart

below:

**Type of Policyholder Commission Rate**

**(percentage of premium)**

**Financial Institutions 8%**

**Exporters**

Small Business **30%\***

Multi-Buyer Policyholders **12%**

Single-Buyer Policyholders **10%**

**Administrators**

Umbrella Policy **30%\***

Trade Association Policy **10%**

**Lessors**

(whether a financial institution or an exporter)

Operating Lease Policy **20%**

Financing Lease Policy **10%**

\*At Ex-Im Bank\'s discretion, this percentage will increase to 40% for
those brokers who meet certain criteria regarding support of small
business.

**COMMISSION PAYMENTS**

\- The full amount of all premiums are due at the appropriate lockbox on
or before the date specified in the policy. Insurance

brokers should not remit premiums \"net\" of commission.

\- Commission payments will be made monthly.

\- No commission payments will be made on advance premium.

**BROKER CHANGES ON EXISTING POLICIES**

Ex-Im Bank policyholders may appoint or change their insurance broker at
any time. Insurance brokers appointed after a policy is

issued will be [recognized on the first day of the next month after the
receipt of the policyholder\'s written notice]{.underline} appointing an

insurance broker of record. Acknowledgment by Ex-Im Bank of a
policyholder\'s appointed insurance broker is made by means of a policy
endorsement. Insurance brokers acknowledged by Ex-Im Bank [are eligible
for commissions with respect to transactions occurring after the
effective date]{.underline} of the endorsement.

WHO TO CONTACT: For additional information, please contact a Regional
Office or:

EXPORT-IMPORT BANK OF THE U.S., INSURANCE DIVISION

811 VERMONT AVENUE, N.W., WASHINGTON, D.C. 20571

TEL NO (202) 565-3630 or 1-800-565-EXIM FAX NO. (202) 565-3675 INTERNET
http://www.exim.gov

**Regional Offices**: MID ATLANTIC (212) 809-2650 MIDWEST (312) 353-8081

NORTHEAST (212) 809-2650 SOUTHEAST (305) 526-7436

SOUTHWEST (281) 721-0465 WEST: Long Beach (562) 980-4580

EIB-92-79 (02/04) Page 5 of 5