POLITICAL RISK INSURANCE REQUEST FORM *Completed request form can be submitted to or to 613-598-2775 1 CUSTOMER INFORMATION Legal Name of Customer: Address: (Street, City, Province, Country and Postal Code) 2 CONTACT INFORMATION Title: Mr. Ms. Mrs. Name: Fax: Telephone: Email: 3 COVERAGE REQUEST Currency Transfer & Conversion: Foreign government actions resulting in the inability to convert foreign currencies No Yes into hard currencies and/or the inability to transfer such hard currencies out of the foreign country of risk. Expropriation: Foreign government action that results in a loss of a foreign equity investment or assets deployed in the No Yes foreign country of risk (e.g. outright taking of the investment or assets). Political Violence: Violent or hostile acts in the foreign country, aimed at changing or overthrowing the foreign No Yes government or changing the laws or policies of the country (e.g. war, insurrection, revolution, terrorism) resulting in damage, deprivation or destruction of asset or in the inability to conduct business operations. Coverage amount required: Amount: USD CAD EUR Coverage date and duration of coverage: (dd/mm/yyyy) 4 INVESTMENT (the (Covering the shares in a Foreign Enterprise (as defined below), but not any specific “Investment”) assets) (to be completed only if requesting investment cover) Specific location of Investment (including country): Description of the scope and nature of the Investment: Currency: Value: Value of Investment: Basis of determination (e.g: Net book value): Name and your percentage of Foreign Enterprise Legal Name: ownership of the company that will operate the Investment (“Foreign Your percentage of ownership: Enterprise”): Name and percentage of ownership in the Investment of other shareholders, if Name of other shareholder: Percentage of ownership: any: (If more than one please provide additional information on a seperate sheet) Have any of the assets or your shares forming part of the Investment been No Yes pledged as security? Are you aware of any significant environmental risks associated with No Yes any business which would be the subject of this Request Form? 5 ASSET(S) (the (Covering physical assets and funds in foreign bank accounts. (to be completed only if requesting “Assets”) asset cover)
POLITICAL RISK INSURANCE REQUEST FORM *Completed request form can be submitted to or to 613-598-2775 1 CUSTOMER INFORMATION Legal Name of Customer: Address: (Street, City, Province, Country and Postal Code) 2 CONTACT INFORMATION Name: Mr. Ms. Mrs. Title: Telephone: Fax: Email: 3 COVERAGE REQUEST Currency Transfer & Conversion: Foreign government actions resulting in the inability to convert foreign currencies into hard currencies and/or the inability to transfer such hard currencies out of the foreign country of risk. No Yes Expropriation: Foreign government action that results in a loss of a foreign equity investment or assets deployed in the foreign country of risk (e.g. outright taking of the investment or assets). No Yes Political Violence: Violent or hostile acts in the foreign country, aimed at changing or overthrowing the foreign government or changing the laws or policies of the country (e.g. war, insurrection, revolution, terrorism) resulting in damage, deprivation or destruction of asset or in the inability to conduct business operations. No Yes Coverage amount required: Amount: USD CAD EUR Coverage date and duration of coverage: (dd/mm/yyyy) 4 INVESTMENT (the “Investment”) (Covering the shares in a Foreign Enterprise (as defined below), but not any specific assets) (to be completed only if requesting investment cover) Specific location of Investment (including country): Description of the scope and nature of the Investment: Value of Investment: Currency: Value: Basis of determination (e.g: Net book value): Name and your percentage of ownership of the company that will operate the Investment (“Foreign Enterprise”): Foreign Enterprise Legal Name: Your percentage of ownership: Name and percentage of ownership in the Investment of other shareholders, if any: (If more than one please provide additional information on a seperate sheet) Name of other shareholder: Percentage of ownership: Have any of the assets or your shares forming part of the Investment been pledged as security? No Yes Are you aware of any significant environmental risks associated with any business which would be the subject of this Request Form? No Yes 5 ASSET(S) (the “Assets”) (Covering physical assets and funds in foreign bank accounts. (to be completed only if requesting asset cover)
application-PRI.docx