Z - Notification of a threat of an insurance loss

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NOTIFICATION OF A THREAT OF AN INSURANCE LOSS
GIC type Z
  Insurance Contract number:
  Insurance Decision number (for framework contracts):
  Cause of an insurance loss according to GIC Z Art. VII.:
  Supplementary insurance of exchange rate risk (for contracts before December 31, 2006):
 
  Dispute between Exporter and Importer:  
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. Principal
  Commercial name:
  Company Identification No.:
  Seat:
  Phone:
  Fax:
  E-mail:
  Contact Person:
  Bank Connection:
III. Beneficiary
  Commercial name:
  Seat:
  State:
  Subject:  
  Phone:
  Fax:
  E-mail:
  Contact Person:
  Bank Connection:
IV. Data on a threat of an insurance loss:
Guarantee number Calling (currency) Date of calling
  Share of goods of Czech origin in the total export exceeds 50%:    
V. Calling of the guarantee according to Art. VII.:
  Unfair Fair
Principal has not breached
contractual obligations 		political  
  Bid bond
  Advance payment bond
  Performance bond for Export Contract
  Other
VI. 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 in order to prevent an insurance loss (must be filled-in):
VII. 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
VIII. 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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