D - Notification of a threat of an insurance loss

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NOTIFICATION OF A THREAT OF AN INSURANCE LOSS
GIC type D
  Insurance Contract number:
  Insurance Decision number (for framework contracts):
  Cause of an insurance loss according to GIC D:
  Supplementary insurance of exchange rate risk (for contracts before December 31, 2006):
 
I. Insured
  Commercial name:
  Company Identification No.:
  Seat:
  Phone:
  Fax:
  E-mail:
  Contact Person:
  Bank Connection:
  Authorised Person 1):
1) Person for whom the right to indemnification comes into existence as a result of an insurance loss - to be filled in only if it is other person than the insured
II. Debtor
  Commercial name:
  Seat:
  State:
  Debtor:  
  Phone:
  Fax:
  E-mail:
  Contact Person:
  Bank Connection:
III. Data on a threat of an insurance loss:
Currency From To Principal Interest
rate 		Number
of days 		Interest Owed
principal
Total  
Owed principal + interest  
  Share of goods of Czech origin in the total export exceeds 50%:    
IV. Commentary:
  Description of business transaction:
  Reasons and circumstances leading to a threat of an insurance loss (must be filled-in):
  Following steps have been made for recovery/ensurance of the receivable (must be filled-in):
V. Instruction
  • the form has to be duly filled-in and signed by a person authorized to act outwardly on behalf of the company
  • the insured will continue in all necessary measures in cooperation with the insurer to prevent origination of an insurance loss or to lower its extent
  • the insurer has the right to take all necessary measures in cooperation with the insured or independently leading to prevention of an insurance loss or to lowering of its extent
VI. Annexes
(demonstrative enumeration, a list of annexes will be specified by the Insurer upon receipt of this Notice)
  Number of attachments:  
  Date:
Signature of insured:   .......................................................................................
 
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