FORM No.
121
EXPORT CREDIT GUARANTEE
@'E
CORPORATION OF INDIA LTD.
pRoPosAL FORM FOR SHIPMENTS (COMPREHENSIVE RISKS) POLICY/
SMALL EXPORTERS POLIGY
We hereby apply for Shipments (Comprehensive Risk) Policy / Small Exporters Policy
which we have already read:
,1,
Name of the
Company
(,, I ,s",".*e< Pd r rf,
2. Address
ttxt rto " v 4r+t FL@R . V x1'; u a MfrD-
Lt
0rA0E< gvqrxt;Sc fArlE- rtuL tNDIA
ciy f Ap+2Nlxj Pin l2l o 13
Phone QTtta? Q4Q3 Fax
E-Mair €f hov!(d r'olofu,+le^ :' Com
l.E.C. No.
AA].I cA Uq N (Attach photo Copy)
h xs f C V lq N (Attach Photo Copy)
Company PAN
No.
4.
ffl['.].,..,0 tcrcr XArurc
cnv fA 4.fDanq,O Pin I
Phone
E-Mail
5. Contact Person
l<rt n*rr ?At-
6. Status of (l) Proprietorship Partnership Pvt. Ltd.
the Unit Co.
Public Ltd. Co. Public Ltd. Co. 100% Eou
(Listed) (Unlisted)
PSU
(t t) Export House Star Trading Other
House
Trading House Super Star
Trading House
7. Names of Proprietor / Partners / Directors (Separate sheet may be attached if
necessary)
st. Names Son/ Dauqhter/ Wife of Date of Birth PAN No.
flonfrUw q,ETltr Q AT,EH lconhLle1ttl ir nqlnw q& Btrfsr%<
8. Names of Sister Concerns (With Addresses):
9. Do you make shipments to your overseas associate
concerns? I Yes" I No I
lf yes, do you want to cover the same against
@|isldso-
10. Cover required: No option to Exclude Non L/C shipments
L/C Shipments: (Mark "X" at the appropriate box)
(iii) Political risk and lnsolvency and Default of L/C opening bank f-f_l
11. Anticipated turnover for next 12 months (in Rs.), Please give the detail as per the
enclosed annexure 1.
Under L/C
1.5 c fL-
Under Non L/C
3'5 cK
Total
, CR.
12. Whether you are availing of export credit insurance cover/ factoring facility for
exports from any other Insurer/Factor- Yes / No.
If yes, then the following details need to be obtained:
1. Name of the InsurancelFactoring Company
2. Details of the Policy/ facility taken:
3. Value of Export Turnover insured/ factored
4. Name(s) & address of the buyers insured/factored
5. Other details, if any
(MINIMUM DEPOSIT PREMIUM PAYABLE FOR STANDARD POLICY lS Rs. 10,000/- FOR
SMALL EXPORTER POLICY lS Rs. 5,000/- or Three months premium based on the projected
export turnover whichever is higher.)
We accept the premium rate quoted by you. Cheque for Rs. ts
enclosed towards minimum premium.
For COLOSSUSTEX Pf\TE !-l['ilTED
Prace: f|mn$A D Signature:
W,
Authcrized Sio t" rtlerrv
Date: Office Stamp:
Note: Wherever space provided is insufficient, attach separate sheet.
lncase of Renewal, please submit the following statement duly attested by your
banker(s), indicating export turnover during the last 12 months.
SHIPMENT MADE BY US DURING THE PERIOD TO
N RUPEES
1. Total shipments made against UC Rs. t-5 c A
2. Total shipments made against DA/ DP/ CAD Rs. 70 c8
3. Total shipments made against other terms of
payment (Specify terms of payment)
a o Y^ hinq:'f r' CA P Rs. Llo C12 -
Rs. lo c 6
Advance Payment
Joy^ ADuttNc{
GRAND TOTAL Rs. 5l,f c A
fror COLOSSUSTEX oHu l-fii4il"Ei,,
(w
Authofzed Signatory
Seal and Signature of Exporter Seal and Signature of the Exporter's Banke(s)
Registered Office : Express Towers, Nariman Point, Mumbai-400 021
Tel No. 22845452 I 22845471 -73 Fax:22045253 I 22023267
insurer: Provided that acceptance by an insurance agent of commission in
connection with a policy of life insurance taken out by himself on his own
life shall not be deemed to be acceptance of a rebate of premium within
the meaning of this subsection if at the time of such acceptance the
insurance agent satisfies the prescribed conditions establishing that he is
a bona fide insurance agent employed by the insurer.
Any person making default in complying with the provision of this section
shall be liable for a penalty which may extend to ten lakh rupees.
3. Whether there is any change (a) in the management of the Company (b)
address of the Company
i'or COLOSSU STEX P RI\/AT r. l-l iilli-E i:
Date:
Place:
b-75 -2_Lj
flArAA6A2 (Auth o
D
riz6$ Bffiidtgqry' u'Y
Annexure - 1
Proiected Export Turnover for next 12 months
Name of the Gountry Antlcipated Terms of Maxmium
buyer Turnover (!NR) Payment Amount out
standing at any
point of time
[gLtWtotntV
T€KCrtrL Dokvtt aofi ro.vE Scft. CAO
4N0Wrlflc
tE Yrf t iflt?*Atr \* CHILe lcrz^ ?QY-AdvAn(€ -
4a.r:AhffiTT,L
hzrz,k*0trV -Tv rtrcIv €
4r.,lrrrrr 0lrvvd 2({? - f At)
' itv -ri-r Crre4
FA/n:r.LA fu ltrgnrtmn 9' Lac ^
?;f"lwrxs L
?r0I (,ara \tztLE(d\n^ t cr. \o',.Av"r;W
o?€KTa<c ItF^'
v?w< -36i/. 'Tulrrv i I ctL- Y>. Nvcl*a-
a-...t. /' AD -
N.rlhlagn t U>tEtcistrt^ I c/?. -4<'/. " lAlv",*'a.-
IOY ls.arnl ?
1. l/ We hereby apply for SCR / SEP Policy of ECGC
Ltd. (Formerly Export Credit Guarantee Corporation of lndia Limited). l/
We have read and understood the terms and conditions of the Policy and
found the same to be suitable for my/our requirements. l/VVe have also
obtained necessary clarification about the benefits, the details of
documents/evidence required, procedure to be followed for settlement of
claims, if any, and l/we further undertake not to seek refund of premium
from ECGC for whatsoever reason except as provided under the Policy.
2. PROHIBITION OF REBATES Section 41(1) in The lnsurance Act, 1938
No person shall allow or offer to allow, either directly or indirectly, as an
inducement to any person to take out or renew or continue an insurance in
respect of any kind of risk relating to lives or property in lndia, any rebate
of the whole or part of the commission payable or any rebate of the
premium shown on the policy, nor shall any person taking out or renewing
or continuing a policy accept any rebate, except such rebate as may be
allowed in accordance with the published prospectuses or tables of the
Dear Sir/Madam,
Re:- Pavment of Premium bv RTGS/NEFT
As discussed, we are providino the bank details for RTGS remittance below:
Bank IDB! Bank Ltd.
A,/c number v0034231 33000053
RTGS IFSC Code tBK10000004
NEFT IFSC code !BK10000004
A/c Name / Beneficiary Name ECGC Ltd., Faridabad Branch
Bank Branch Nariman Point, Mumbai
Bank Branch Address 224-A, MITTAL TOWER, A W!NG,
NARIMAN POINT. MUMBA! .21
MICR Code 400259002
Comments/ narration Exporter Name
After sendino the RTGS/NEFT. olease mark a copv at [email protected]
..KINDLY REMIT THE AMOUNT TO US ONLY UNDER GUSTOMER MODE OF
RTGS/NEFT"
