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Coface Austria Kreditversicherung AG Sucursala Romania Calea Floreasca no 39, et.2, Sector 1 Bucuresti Romania T. +40 212121326 F.

+40 212121329

Cerere de asigurare
Application form Globalliance
1) Toate sumele trebuie completate n mii EUR / All amounts should be stated in thousands of EUR 2) Vnzrile (cele la export) trebuie completate far TVA / Sales figures (export only) should be exclusive of VAT 3) Sumele reprezentnd creane clieni, pierderi sau sume cu scaden depit nu trebuie s includ dobnzi sau alte penaliti contractuale pentru ntrzierile la plat. / Figures for receivables, losses and overdue debts should not include any
interest or contractual penalties for late payment.

A. Informaii despre solicitantul asigurrii / Information on the applicants business Nume companie / Name of company ______________________________________________________________ ______________________________________________________________ Adresa / Address Telefon / Telephone ______________________________________________________________ Fax ______________________________________________________________ ______________________________________________________________ E-mail Cod unic de nregistrare (CUI) / Tax ID ______________________________________________________________ Numr de nmatriculare / Business register number ____________________________________________________ Acionari / Shareholders ______________________________________________________________ Capital n EUR / Capital EUR ______________________________________________________________ Firme asociate sau controlate / Associated or dependent firms ____________________________________________________ B. Domeniul de activitate / Line of business ____________________________________________________ _________________________________________________________________________________________________________________ C. Pierderile nregistrate din total vnzri pe tipuri de clieni i sectoare de activitate n %
Breakdown of total sales by customer type and sector in %

divizia / branch (ex: alimentar, oel) / (e.g.: food, steel)

n % / in %

tipul clientului / type of customers n % / in % (ex. mici comerciani, angrositi, hipermarketuri)


(e.g. retailers, wholesailers, hypermarkets)

______________________________ ______________________________ ______________________________ ______________________________ ______________________________

_________ _________ _________ _________ _________

______________________________ ______________________________ ______________________________ ______________________________ ______________________________

_________ _________ _________ _________ _________

D. Vnzrile pe credit estimate pentru urmtoarele 12 luni pentru care dorii asigurare (exclusiv vnzrile ctre companii de stat i firme care se afl sub controlul dvs.) / Projected sales on credit terms, during the 12 consecutive months to be covered by credit insurance
(exclusive sales to public entities and dependent companies)

EUR Export / EUR Export ________________________

EUR Intern / EUR Domestic

_________________________

E. Solicitai asigurare pentru (v rugm selectai) / Insurance coverage shall apply to (please mark) export / export intern / domestic Riscuri asigurate (v rugm selectai) / Insured risks (please mark) faliment / insolvency faliment i neplat prelungit (nencasare i colectare)
insolvency and protracted default (default & collection)

Informatiile vor fi tratate ca strict confidentiale si vor fi folosite de Coface numai n scopuri interne. This information shall be treated as strictly confidential and shall be used Coface internally only.

Coface Austria Kreditversicherung AG Sucursala Romania Calea Floreasca no 39, et.2, Sector 1 Bucuresti Romania T. +40 212121326 F. +40 212121329

F. Date financiare din ultimii 3 ani / Financial data for recent 3 years
anul
financial year

cifra de afaceri anual


annual turnover

nr. clieni (la sfritul anului)


number of customers (year-end)

pierderile nete*
net amount* lost receivables

nr. de cazuri n care s-au nregistrat pierderi


number of losses (nonpayment)

cea mai mare pierdere


highest single loss

2004 2005 2006 *pierderile efective din creane minus toate sumele recuperate (sume datorate de ctre debitorii pentru care exist o hotrre judectoresc n favoarea dvs.; n cazul reorganizrilor judiciare/lichidrii se scad toate sumele recuperate ca urmare a deinerii unor angajamente ferme, garanii etc.) / *lost receivables minus all amounts recovered (amounts owed by debtors due to court enforcement proceedings, creditor
composition/liquidation proceedings etc minus all amounts recovered through pledges, guarantees etc.)

G. Principalii clieni / Major customers


nume, CUI i adres
customer name,tax ID and address

limita de credit solicitat


requested credit limit

vnzrile pe credit estimate pentru urmtoarele 12 luni


projected sales on credit terms (next 12 months)

sumele de ncasat (la sfritul lunii precedente)


receivables(end of last month)

termen de plat
Actual payment period

observaii
Remarks

H. Facturi curente nencasate / Breakdown of current receivables sume n EUR nr. Clieni
receivables in EUR number of customers

total facturi la sfritul lunii precedente


total receivables at end of last month

sub 7.500 EUR


below 7.500 EUR

ntre 7.500 i 15.000 EUR


from 7.500 to 15.000 EUR

ntre 15.000 i 50.000 EUR


from 15.000 to 50.000 EUR

peste 50.000 EUR


over 50.000 EUR

I.

Total creane clieni la sfritul fiecrui trimestru al anului anterior / Total receivables at end of each quarter in the last financial year Trim I / 1st quarter Trim II / 2nd quarter

__________________________ __________________________

Trim III / 3rd quarter Trim IV / 4th quarter

__________________________ __________________________ 2

Informatiile vor fi tratate ca strict confidentiale si vor fi folosite de Coface numai n scopuri interne. This information shall be treated as strictly confidential and shall be used Coface internally only.

Coface Austria Kreditversicherung AG Sucursala Romania Calea Floreasca no 39, et.2, Sector 1 Bucuresti Romania T. +40 212121326 F. +40 212121329

J. Pierderile nregistrate n funcie de ara clientului / Breakdown of customers by country


ara
Country

cifra de afaceri la export (anul trecut)


export turnover (last year)

creane clieni (la sfritul anului trecut)


receivables (end of last year)

nr. clieni (la sfritul anului trecut)


number of customers (end of last year)

cifra de afaceri estimat (n urmtoarele 12 luni)


projected turnover (next 12months)

Total

K. Reinerea dreptului de proprietate a bunurilor livrate pn la momentul achitrii acestora Retention of title is included in terms of sale da / yes

nu / no

L. Termene de livrare i de plat (v rugm completai spaiile punctate) / Terms of delivery and payment (please fill out) Factura este emis dup _________________ zile de la livrarea bunurilor sau prestarea serviciilor
The invoice is issued Range of agreed payment periods

_________________

days after delivery of goods or provision of services

Intervalul termenelor de plat _________________ zile / days Perioada efectiv de plat


Actual payment period

n medie: _________________ zile / average days

_________________ zile / days

M. Excepii de la termenele normale de plat / Exceptions to normal payment terms


clientul sau categoria de clieni
customer or customer category

termenele de plat
payment terms

cifra de afaceri estimat (urmtoarele 12 luni)


projected turnover (next 12 months)

N. Total facturi cu scaden depit la sfritul lunii trecute / Total of overdue receivables at end of last month
pna la 30 zile
up to 30 days

30 - 60 zile
30 - 60 days

60 - 120 zile
60 - 120 days

120 - 180 zile


120 - 180 days

peste 180 zile


over 180 days

O. Creane cu grad ridicat de risc / Receivables at risk Clieni pentru care ai suspendat livrrile/relaiile comerciale ca urmare a riscului de daun i clieni care au ntrzieri la plat mai mari de 90 de zile. / Customers with whom your company has suspended commerce/deliveries due to the risk of default/arrears and customers
who are in arrears with their payment for more than 90 days.

Clientul
Customer

suma creanei
amount receivable

data scadenei
original payment deadline

zile ntrziere
days overdue

aciunile ntreprinse
precautionary action taken

Informatiile vor fi tratate ca strict confidentiale si vor fi folosite de Coface numai n scopuri interne. This information shall be treated as strictly confidential and shall be used Coface internally only.

Coface Austria Kreditversicherung AG Sucursala Romania Calea Floreasca no 39, et.2, Sector 1 Bucuresti Romania T. +40 212121326 F. +40 212121329

P. Informaii suplimentare (v rugm ataai copii) / Sumarul curent al registrului de clieni, angajamente de plat confirmate (dac exist) etc. / Additional information (please attach copies) /
current summary of the business register, confirmations of assignment (if any), tax ID

V rugm trimitei formularul / Please send this application form pe e-mail la / via e-mail to teodora.dumbraveanu@coface.ro sau / or prin pot / via post to Coface Austria Kreditversicherung AG Sucursala Romania, Calea Floreasca no 39, et.2 Sector 1, Bucuresti, Romania Persoana de contact
Contact person

Telefon
Phone

E-mail
E-Mail

__________________________ __________________________

__________________________ __________________________

__________________________ __________________________

Solicitantul / The applicant - declar c toate informaiile coninute n aceast cerere sunt corecte i complete
- declares that all information contained in this application is accurate and complete;

- este de acord ca acest cerere s fac parte integrant din contractul de asigurare ce va fi semnat ulterior.
- accepts that this application form will constitute an integrated part of any insurance contract signed.

- este de acord ca datele furnizate sa fie pastrate si folosite n analize ulterioare de Coface. - agrees that provided data can be stored and used for a further processing within Coface.

__________________________________
Locul i data / Place and date

__________________________________________________
Semntura persoanei autorizate s reprezinte compania (tampila companiei)
Signature of companys authorized representative (company stamp)

Informatiile vor fi tratate ca strict confidentiale si vor fi folosite de Coface numai n scopuri interne. This information shall be treated as strictly confidential and shall be used Coface internally only.