For coverage on a single named buyer (debtor) — either as a standalone single-buyer policy or as an endorsement adding a named buyer to an existing trade credit policy. Please complete all applicable sections. Fields marked * are required. Attach the most recent annual financial report and any product brochures where indicated, then submit. Impello will position the risk and present it to the appropriate trade credit underwriting markets on your behalf.

1. Applicant & Buyer

1.1 Applicant

Legal Name *

Address

1.2 Buyer

Legal Name *

Address

Already insured with Impello? If the Applicant is presently insured under an existing trade credit policy placed through Impello Global, Questions 1.3 through 1.8 may be omitted.

Yes — hide 1.3–1.8 No

1.3 Applicant's most recent annual financial report (attach below)

Upload in the Document Checklist at the end of this form. Product brochures may also be included if available.

1.4 Number of years selling to Buyer on credit terms

1.5 Products to be sold to the Buyer

Country(ies) from which products are sourced

Supplier of products, if other than Applicant

1.6 Are the products standard or custom-made?

Standard Custom-made

1.7 How easily could alternate Buyers be found, if necessary?

1.8 Would products need modification if sold to other Buyers and, if so, what would the cost of such modification be?

2. Buyer Information

2.1 General description of business of Buyer

2.2 Name and address of Buyer's corporate parent, if any

Will a parental corporate guarantee be given? Yes No

2.3 Type of Buyer

2.4 Does the Applicant sell to related companies of the Buyer?

Yes No

If yes, please specify the related companies sold to.

Related Company Name	Relation to Buyer	Projected Annual Purchases from Applicant	Applicant's Max Projected Outstanding Receivables

2.5 Please attach financial statements and all credit information available on the Buyer (and Guarantor, if applicable), including the Applicant's internal credit analysis of the Buyer. Use the Document Checklist at the end of this form.

3. Applicant's Experience with Buyer

3.1 Number of years selling to Buyer

3.3 Current Credit Limit for Buyer

3.2 Sales and high credit with Buyer over the past four years and a projection for the next 12 months

	Next 12 Mo.	20__	20__	20__	20__
Sales
High Credit
Losses, if any	N/A

3.4 Credit Limit requested for Buyer

3.5 Please describe Buyer's general payment pattern

3.6 Expected frequency of shipment(s)

Single Shipment Multiple Shipments

If Single Shipment

a) Expected date of shipment

b) Total Contract Value

c) Contract Effective Date

If Multiple Shipments

a) Maximum projected outstanding receivables during the policy period

b) Total Contract Value (if applicable)

c) Contract Effective Date (if applicable)

iii) Describe Terms of Payment

Specify the proposed payment schedule and the downpayment amount, if any. Identify the documents that will evidence the debt. If Letter of Credit, name the opening bank.

3.7 Currency in which Buyer will be obligated to pay

3.8 Aging of Receivables from Buyer

If the Applicant presently has receivables outstanding from this Buyer and/or any related company, please provide a current aging of receivables.

Date of Aging
Amount not yet due
1 to 60 Days Overdue
61 to 120 Days Overdue
Beyond 120 Days Overdue

Explanation for amounts 61 days or more overdue

3.9 Date and evaluation of the Applicant's most recent visit to the Buyer

3.10 Over the past four years, has the Applicant financed any portion of its accounts receivable from this Buyer with a financial institution on a non-recourse basis?

Yes No

3.11 Has the Applicant ever extended or rescheduled a due date for this Buyer, changed the terms of payment after shipment, or put this Buyer on a payment plan?

Yes No

3.12 Does the Applicant have any knowledge of default, rescheduling, or debt renegotiation by the Buyer in relation to its obligations due to other suppliers?

Yes No

3.13 Does the Applicant have, or plan to obtain, any form of security on the Buyer (liens, escrow accounts, standby Letter of Credit, personal guarantees of owners, etc.)?

Yes No

3.14 Has the Applicant ever purchased credit insurance on this Buyer?

Yes No

Document Checklist

Attach the following with this application. You may also email any item you cannot upload here to your Impello Global representative.

Applicant's most recent annual financial report

Buyer financial statements / credit information (and Guarantor, if applicable)

Applicant's internal credit analysis of the Buyer

Current aging of receivables from the Buyer (if applicable)

Product brochures (if available)

Copy of contract / purchase order / terms of sale (if applicable)

4. Warranty & Declarations

The Applicant warrants, by the signing of this application by an authorized officer:

i. That, to the best of its knowledge, the statements set forth herein are true and that no material information has been withheld; and

ii. That it will not disclose to third parties or to the Buyer any discussions or correspondence relating to this application, nor the existence of any policy that may be issued, except in confidence to the Applicant's insurance broker or bank.

NOTICE TO APPLICANTS: This application does not bind the Applicant or the Company, but it is agreed that this application will be the basis of the contract should a policy be issued, and it will be attached to and made part of the policy. The Applicant represents that if the information supplied on this application changes between the date of this application and the time the policy is issued, the Applicant will immediately notify the Company of such changes.

NOTICE TO NEW YORK AND OHIO APPLICANTS: In New York and Ohio, 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 false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

The undersigned officer of the corporation declares, to the best of his/her knowledge, that the statements set forth herein are true, and agrees to the warranties and notices above. *

You must agree to the declaration to proceed.

Name of Authorized Signatory (Print) *

Title

Corporation

Telephone

Authorized Signature (type full name) *

Date *

Email *

Application Received

Thank you for submitting your Single-Buyer Trade Credit Insurance application. A member of the Impello Global team will review your information and be in touch shortly.

If you have documents you were unable to upload, please email them to your Impello Global representative.

info@impelloglobal.com

19689 7th Ave NE, Poulsbo, WA 98370

Privacy Policy ‍ ‍Terms of Services

© 2026 by Impello Global