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Single Buyer Application for Credit Insurance

All information provided will be held in strict confidence

One Source Risk Management and Funding, Inc.


1. Company Name:      

2. Address:      

3. Telephone:       4. Fax:      

5. Year Incorporated:       6. Primary Line of Business:      

7. Trade styles:      

8. Policy Contact, Title:       e-mail:      


1. Buyer Name:      

2. Address:      

3. Telephone:       4. Fax:      

5. Amount of Coverage Requested:      

6. The credit coverage requested is (check one):

 Comprehensive (Commercial and Political)  Commercial only  Political only

7. Is pre-delivery coverage requested?  Yes  No

8. Requested Exclusions:

Confirmed Letters of Credit?  Yes  No

Unconfirmed Letters of Credit?  Yes  No


9. Describe the goods and/or services: Description Percentage




10. Were changes implemented last year or are changes contemplated next year with respect to the products sold, the credit terms offered, or any other material aspects of the trading relationship(s)?

 Yes  No If yes, describe:      

11. Anticipated maximum amount of insured receivables for the buyer during Policy Period applied for:


12. Are additional securities or guarantees supporting the buyer's credit?  Yes  No If yes, describe.



As a basis for the policy hereby applied for, and for any Policy of Credit Insurance which may hereafter be issued to us, we warrant the following statement of our sales, losses and amounts owing by debtors under or seeking general extension to be correct and represent the combined experience of our company and that of all entities to be insured by the policy.

1. Number of years granting credit to the buyer:      

2. Details of credit experience for the past three fiscal years:


Total Sales


Amount of Highest Credit Outstanding













3. Describe the buyer’s performance history in working with you:  No experience  Prompt

 1 to 30 days slow  31 to 60 days slow  More than 60 days slow (explain)

4. Within the past 12 months have any receivables been rescheduled or had other problems associated with them?  Yes  No

If yes, provide details (original amount, original sales terms, current balance, rescheduled terms, and a brief explanation).      

5. Have you visited the buyer's place of business during the last 24 months?  Yes  No

If yes, date of last visit:       Provide copy of latest visit report, if any.

6. Receivables outstanding from the buyer at the end of the most recent and the three previous fiscal quarters:

Quarter Ended:                        



1. Current status:  Bidding in process  In negotiations

 Contract(s) executed  Firm order(s) issued

2. Number of transactions:  Single transaction (Complete section 3)

 Multiple transactions (Complete section 4)

3. Single Transaction:

a. Date of delivery:       b. Amount of contract:      

c. Maturity date for credit:       d. Payment Terms:      

4. Multiple Transactions (Copies of delivery schedule may be submitted to describe the transactions.):

a. Date of initial delivery:       b. Date of final delivery to be insured:      

c. Total sales or purchases:       d. Amount of credit limit requested:      

e. Payment Terms:      

5. Product will be shipped from the following countries and by whom:      

6. Product will be shipped to the following countries and by whom:      

7. Currency in which debt is payable:      

8. What documents will you have to evidence the buyer’s obligation to pay you (e.g. written purchase orders,

invoices, bills of lading, drafts, etc.)      


Provide any additional information available which would be useful for assessing the credit including but not limited to current credit agency reports, bank reports and trade references, any written credit analysis prepared by the Applicant, interim financial statements, and two to three years annual financial statements of the buyer and any guarantors.

Any person who, with intent to defraud or knowing that (s)he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Broker of Record

We hereby appoint One Source Risk Management and Funding, Inc. as our Broker of Record for all Credit Insurance Related purposes. This appointment supersedes any previous appointments and allows One Source Risk Management and Funding, Inc. to handle all communication between ourselves and the various carriers, along with their representatives.

Signing this application does not bind you, the undersigned, to purchase credit insurance. The information contained here in may be used to obtain quotations for coverage and will remain confidential.

If a policy is issued, such policy, along with this application and the policy declaration shall constitute the entire agreement between the applicant and the insurance carrier not withstanding any statement or agreement made by any representative of One Source Risk Management and Funding, Inc. to the contrary.

Applicant Company:


By: (Print Name)








A policy cannot be issued unless this application is properly signed and dated.

OS SB Fillable P.O. Box 15340 Page 4 of 4

06-11-2013 Portland, ME. 04112

Phone: 866.463.4741 Fax: 207.828-9512

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