Apply for Trade Credit Insurance

Complete the form below to begin your trade credit insurance application. All fields marked with * are required.

Section 1: Applicant's Information

Company Name

Company name is required

Address

Address is required

Primary Contact

Primary contact is required

Valid email is required

Telephone

Website

Business Description

Types of Buyers and Estimated Percentage of Sales to Each

Domestic % of Sales

Foreign % of Sales

Products/Services Sold and Countries from Which Products are Sourced

Parent/Subsidiary/Affiliate Details

Company Name	Address	Relationship to Applicant

Coverage Requested

Domestic

Foreign

Both

Coverage type is required

Years Selling on Credit Terms (Domestic)

Years Selling on Credit Terms (Export)

Primary Reason for Credit Insurance

Risk Mitigation

Financing

Other

Primary reason is required

Please Specify Other Reason

Credit Facility Details (if applicable)

Do You Currently Have a Credit Insurance Policy?

Yes

This field is required

Insurer Name

Policy Expiration Date

Section 2: Sales and Loss Information

Sales for Last 4 Years + Projected Next 12 Months

Year	Domestic Sales	Domestic Bad Debt	Foreign Sales	Foreign Bad Debt

Maximum Outstanding Receivables (Domestic)

Maximum Outstanding Receivables (Foreign)

Do You Have Seasonal Sales Patterns?

Yes

This field is required

Describe Your Seasonal Pattern

Projected Buyer Credit Limits Distribution

Credit Limit Range	Number of Domestic Accounts	Number of Foreign Accounts
$0 - $25,000
$25,001 - $50,000
$50,001 - $100,000
$100,001 - $250,000
$250,001 - $500,000
$500,001 - $1,000,000
Over $1,000,000
Total

Five Largest Domestic Buyers

Buyer Name / City / State	Prior Year Shipment Volume	Payment Term	Credit Limit Needed

Total Domestic Receivables Outstanding As Of:

Domestic Receivables Aging

1-30 Days	31-90 Days	91-180 Days	181-360 Days	Over 360 Days

Have You Had Past Due Domestic Accounts with Collection Service in Last 12 Months?

Yes

This field is required

Provide Details

Domestic Losses in Past Three Years

Year	Amount ($)	Number of Losses	Largest Loss ($)	Reason for Loss

Five Largest Foreign Buyers

Buyer Name / City / Country	Prior Year Shipment Volume	Payment Term	Credit Limit Needed

Total Foreign Receivables Outstanding As Of:

Foreign Receivables Aging

1-30 Days	31-90 Days	91-180 Days	181-360 Days	Over 360 Days

Have You Had Past Due Foreign Accounts with Collection Service in Last 12 Months?

Yes

This field is required

Provide Details

Foreign Losses in Past Three Years

Year	Amount ($)	Number of Losses	Largest Loss ($)	Reason for Loss

Section 3: Credit and Collection Procedures

Credit Assessment and Approval Process

Do You Have a Formal Written Credit Policy?

Yes

This field is required

Information Required to Approve or Renew a Credit Limit

Do You Obtain Financial Statements from Customers?

Yes

This field is required

Provide Details on Frequency and Use

How Often Are Credit Limits Reviewed?

Credit Monitoring Policies

Collection Process Details

Section 4: Additional Information & Declaration

Required Documents Checklist
Please ensure the following documents are attached to your application:

Financial statements (2 years + most recent quarterly)
Current accounts receivable aging report
Formal written credit procedures (if available)
Product brochure (if available)

Financial Statements (2 years + most recent quarterly)

Current AR Aging Report

Formal Written Credit Procedures (if available)

Product Brochure (if available)

Broker of Record Statement

We [Company Name], appoint Impello Global Insurance Services, LLC, as our exclusive broker of record for trade credit insurance. This appointment will remain in effect until cancelled in writing.

NOTICE TO APPLICANTS
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

I declare that the information provided in this application is, to the best of my knowledge, true and complete and that I am not aware of any circumstances that I have not disclosed which may influence the assessment of risk.

I agree to the above declaration

You must agree to the declaration to proceed

Typed Signature

Signature is required

Date

Name (Print)

Printed name is required

Title

Company