OmniForm Form - Get as DOC by HC1203060522

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									                                             QBE INSURANCE CORPORATION
                                             QBE the Americas
                                             Wall Street Plaza
                                                                                Home Office
                                                                                1515 Market Street, Suite 1210
                                                                                                                                                        Trade Credit Insurance
                                             88 Pine Street
                                             New York NY 10005
                                                                                Philadelphia, PA 19103
                                                                                                                                                                               Claim Form
                                             Tel: (212) 894 7774
                                             Fax: (212) 422 2424

                                             www.qbeusa.com
                                             www.qbetradecredit.com                                                                   Full information must be given if delays are to be avoided.
                                                                                                                                        Use the currency unit you elected to have claims paid in.


  Your Claim - Details
   1. Name of Insured (or Joint Insured)                                                                                                    Policy Number


   2. Your Debtor's Name - Insured Buyers correct legal entity                                                                              Policy Number (if applicable)


  3. Debtor's Industry



  4. Debtor's Address                                                                                   Zip Code                                       State


  Telephone                                                                                              Fax



  5. Date of Loss or Insolvency of Debtor                                                                Type of     Insolvency              Pr otr acted Default               Contr act Repudiation
                                                                                                         Loss:
   For non insolvency claims please provide details in regard of the reason for non payment                                                          Political Risk                         Other




   Has the Debtor raised any dispute or complaint in regard to the terms of the contract                                                                       If Yes, please give details
                                                                                                                          Yes               No


  6. Total amount owed by Debtor                                                                        Policy Currency


  7. Amount you are claiming under the policy

                                                                                                         Please use the last page of this form to detail your calculation.


  General Information
  8. Do any of the following apply to this account? If 'yes", give details including all documentation and advise what action you are taking to enforce your rights.

     a) Personal Guarantee/Other Security                                                       Yes            No
     b) Contra Trading or Set-off
                                                                                                Yes            No
     c) Cash Sales
                                                                                                Yes            No
     d) Retention of Title Clauses
                                                                                                Yes            No
  9. Date account first opened on credit terms

   10. Terms of payment agreed with Debtor (please be specific)




   11. a) Was credit approved under an Endorsed Credit Limit?                                                                   If "yes", provide copy of endorsement. If "no", refer to (b)
                                                                                                Yes            No
       b) Was credit approved under your Discretionary Limit?                                   Yes            No               If "yes", provide copy of credit file for the respective buyer

   If ''yes” ... was credit granted relying on:                  (i) Financial Information      Yes            No

                                                          (ii) Credit Report/Trade Report       Yes            No

                                                                   (iii) Trading Experience     Yes            No

                                                                     (iv) Trade References      Yes            No

                                           (v) Other, please provide all pertinent details

  If "yes", to any of (i) to (v) above, provide copies of relevant reports or information                                                              Use back page if additional space is required


Form Reference QBTC-N 003
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 Additional Information
  12. What specific action, including legal action, was taken from the date the account became reportable to the date of! insol vency,
  in pursuing the debtor for payment of the outstanding debt? Please provide all relevant copy documents.




   13. Details of all Unpaid Invoices/Credit Notes (if necessary continue on a separate sheet with the same headings)


                                                                                                                                                 Rate of Exchange
                                                                                                                                               used for conversion to
                                                              Date of Delivery/                                   Gross                         Policy Currency for       Relevant Taxes, Retention
                                                               Dispatch/ Work             Due Date           Invoice Value    Currency         declaring Turnover of        Monies & Other Policy
           Invoice Number              Date of Invoice             Done                 for Payment            (incl. Tax)    Of Invoice           Transactions                  Exclusions




                                                                                                  Totals

   Copies of all outstanding invoices to be provided. If in excess of 20 in number, provision of the last 20 will suffice for initial claim assessment.
   Please also provide all invoices to which credit notes relate with copies of relevant credit notes.


Form Reference QBTC-N 003
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 Additional Information

   14. Ledger Reconciliation for the past 12 month period prior to the oldest unpaid invoice.



           Month of Invoice/Delivery/                Total amount Invoiced in the Month                    Date by Which Monthly Amount
             Work Done/Dispatch                             (incl. application taxes)                               Cleared/Paid                                 Days Credit Taken




  Please attach a copy of your ledger and/or statements covering all entries for the period commencing 12 months
  prior to the oldest unpaid amount up to and including the date of the last transaction with this debtor.



 Supporting Documents
  Please send the originals or photocopies of all documents listed below, otherwise your claim cannot be considered.                                                   Please check


    a) The order(s) relating to outstanding invoices and your CONFIRMATION(S) of the order(s). Please send any evidence of the contract of sale.

    b) The OUTSTANDING INVOICE(S)

    c) The statements of the account for the period commencing 12 months prior to the oldest unpaid invoice and up to the date of last transaction.

    d) All relevant CORRESPONDENCE (especially all communications received from the buyer).

    e) If the debtor is insolvent, any available EVIDENCE OF INSOLVENCY.
      (for example, a notice from the Trustee, Receiver or Liquidator, proof of Chapter 11 filing with court)

    f) Copy of the relevant CONDITION OF SALE

    g) Any NOTICES FROM YOUR BANK advising that Payments Due have been dishonored

    h) Any outstanding BILL(S) OF EXCHANGE, PROMISORY NOTES OR DRAFTS

    i) All BILL(S) OF LANDING or AIRWAY BILL(S) relating to unpaid invoices




  Declaration of Insured and Signature
  We authorize you to disclose your interest in this account to the appropriate authority dealing with the Debtor's affairs.
  On request we shall complete and submit an assignment of the debt to QBE Trade Credit.

  We shall obtain/attach (delete as appropriate) written confirmation from the Liquidator, Trustee, Receiver, or other appropri ate authority, of the amount
  for which we are admitted to rank in the insolvent estate of the debtor or, in the case of any other insured loss, we shall attach Evidence of Debt. It is
  acknowledged that the information/documents requested herein are those usually necessary for adjudication of a claim, but suc h requirements shall not
  be construed as in any way limiting the Definitions and Conditions of the policy as to our duty of disclosure of material fac ts, information as well as to
  QBE Trade Credit's right to examine or obtain copies of letters, accounts, or other docume nts in our possession or control relating to or connected with
  this policy and claim. The information given herein and the attachments are, to the best of our knowledge and belief, true an d correct in every particular.



    Name of                                                                                                               Position in
    Signatory                                                                                                              Company



  Signature                                                                                                                    Date




                NOTE: IMPORTANT STATE INFORMATION - SEE PAGE 4




Form Reference QBTC-N 003
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  Fraud Statements

                                                                                                       Applicable in Maine:
     Any person who knowingly and with intent to defraud any insurance company
     or other person, files an application for insurance or statement of claim                         It is a crime to knowingly provide false, incomplete or misleading information to an
     containing any materially false information, or conceals for the purpose of                       insurance company for the purpose of defrauding the company. Penalties may include
     misleading, information concerning any fact material thereto, commits a                           imprisonment, fines or a denial of insurance benefits.
     fraudulent insurance act, which is a crime and subjects the person to criminal
     and civil penalties. (The state-specific notices listed below supersede this
                                                                                                       Applicable in Minnesota:
     notice).
                                                                                                       A person who files a claim with intent to defraud or helps commit a fraud against an
                                                                                                       insurer is guilty of a crime.

  Applicable In Arizona:
  For your protection, Arizona law requires the following statement to appear on this                  Applicable in Nevada:
  form. Any person who knowingly presents a false or fraudulent claim for payment of a                 Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of
  loss is subject to criminal and civil penalties.                                                     claim that contains any false, incomplete or misleading information concerning a material
                                                                                                       fact is guilty of a felony.

  Applicable in Arkansas, Louisiana, West Virginia:
  Any person who knowingly presents a false or fraudulent claim for payment of a loss or
  benefit or knowing presents false information in an application for insurance is guilty of           Applicable in New Hampshire:
                                                                                                       Any person who, with purpose to injure, defraud or deceive any insurance company,
  a crime and may be subject to fines and confinement in prison.
                                                                                                       files a statement of claim containing any false, incomplete or misleading information is
                                                                                                       subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
  Notice to California Applicants:
  For your protection, California law requires the following to appear on this form: Any
  person who knowingly presents a false or fraudulent claim for payment of a loss is                   Notice to New Jersey Applicants:
  guilty of a crime and may be subject to fines and confinement in state prison.                       Any person who includes any false or misleading information on an application for an
                                                                                                       insurance policy is subject to criminal and civil penalties.

  Notice to Colorado Applicants:
  It is unlawful to knowingly provide false, incomplete, or misleading facts or information to         Notice to New Mexico Applicants:
  an insurance company for the purpose of defrauding or attempting to defraud the                      Any person who knowingly presents a false or fraudulent claim for payment of a loss or
  company. Penalties may include imprisonment, fines, denial of insurance, and civil                   benefit or knowingly presents false information in an application for insurance is guilty of
  damages. Any insurance company or agent of an insurance company who knowingly                        a crime and may be subject to civil fines and criminal penalties.
  provides false, incomplete, or misleading facts or information to a policy holder or
  claimant for the purpose of defrauding or attempting to defraud the policy holder or
  claimant with regard to a settlement or award payable from insurance proceeds shall be               Notice to New York Applicants:
  reported to the Colorado Division of Insurance within the Department of Regulatory                   Any person who knowingly and with intent to defraud any insurance company or other
  Agencies.                                                                                            person files an application for insurance or statement of claim containing any materially
                                                                                                       false information, or conceals for the purpose of misleading, information concerning any
                                                                                                       fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also
  Applicable in Delaware:                                                                              be subject to a civil penalty not to exceed five thousand dollars and the stated value ofthe
  Any person who knowingly, and with intent to injure, defraud or deceive any insurer,                 claim for each such violation.
  files a statement of claim containing any false, incomplete or misleading information
  is guilty of a felony.

                                                                                                       Notice to Ohio Applicants:
  Notice to District of Columbia Applicants:                                                           Any person who, with intent to defraud or knowing that he/she is facilitating a fraud
  It is a crime to provide false or misleading information to an insurer for the purpose of            against an insurer, submits an application or files a claim containing a false or
  defrauding the insurer or any other person. Penalties include imprisonment and/or                    deceptive statement is guilty of insurance fraud.
  fines. In addition, an insurer may deny insurance benefits if false information
  materially related to a claim was provided by the applicant.
                                                                                                       Notice to Oklahoma Applicants:
  Applicable In Florida and Idaho:                                                                     WARNING: Any person who knowingly and with intent to injure, defraud or deceive any
  Any person who knowingly and with intent to injure, defraud, or deceive any                          insurer, makes any claim for the proceeds of an insurance policy containing any false,
  insurance company files a statement of claim containing any false, incomplete, or                    incomplete or misleading information is guilty of a felony.
  misleading information, is guilty of a felony.*
  *in Florida -Third Degree Felony.
                                                                                                       Notice to Pennsylvania Applicants:
                                                                                                       Any person who knowingly and with intent to defraud any insurance company or other
                                                                                                       person files an application for insurance or statement of claim containing any materially
  Applicable in Hawaii:
                                                                                                       false information or conceals for the purpose of misleading, information concerning any
  For your protection, Hawaii law requires you to be informed that presenting a
                                                                                                       fact material thereto commits a fraudulent insurance act, which is a crime and subjects
  fraudulent claim for payment of a loss or benefit is a crime punishable by fines or
  imprisonment, or both.                                                                               such person to criminal and civil penalties.


                                                                                                       Applicable in Tennessee, Virginia:
  Applicable in Indiana:
  A person who knowingly and with intent to defraud an insurer files a statement of                    It is a crime to knowingly provide false, incomplete or misleading information to an
  claim containing any false, incomplete, or misleading information commits a felony.                  insurance company for the purpose of defrauding the company. Penalties include
                                                                                                       imprisonment, fines and denial of insurance benefits.


  Applicable in Kentucky,
  Any person who knowingly and with intent to defraud any insurance company or
  other person files a statement of claim containing any materially false information or
  conceals, for the purpose of misleading, information concerning any fact material
  thereto commits a fraudulent insurance act, which is a crime.




Form Reference QBTC-N 003
                                                                                               Page 4 of 5                                                    Printer Reference TCFUSA 931a (10/05) XXK OI
  Additional Space if Required




                                                  QBE INSURANCE CORPORATION
                                 QBE the Americas, Wall Street Plaza, 88 Pine Street, New York NY 10005
                                 Tel: (212) 894 7774• Fax: (212) 422 2424 • www.qbetradecredit.com




Form Reference QBTC-N 003
                                                              Page 5 of 5                                 Printer Reference TCFUSA 931a (10/05) XXK OI

								
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