Insurance Enquiry

Confidentiality / Authorisation for Limited Disclosure
All information contained in this Enquiry Form will be treated by ATIDI as confidential material. However, ATIDI may be required to disclose the documentation or information contained therein, or attached thereto, to its professional advisors, law enforcement or regulatory authorities, its facility brokers and insurance partners as there may be from time to time, and their reinsurers, it being further understood that this information will only be disclosed by ATIDI on the basis of each recipients(s) acknowledging to observe similar obligations of confidentiality in respect of that information. The Enquirer understands and hereby agrees that, by submitting this Enquiry Form, its attachments and any additional information to be submitted by the Enquirer at a later stage, the Enquirer has expressly authorised ATIDI to disclose the documentation or information contained in the Enquiry form in the manner aforementioned. Fill in to get answers on the insurance solutions we offer
Enquirer
Date of Enquiry
MM slash DD slash YYYY
Name of Company*

(Indicate party [& legal form - private, public, other] on whose behalf enquiry is being made ):
Contact Details*

(Name and address of contact person):
Email*
Telephone and Fax Numbers
Capacity in which Enquiry is being made

(indicate whether broker/ intermediary/ potential insured):
Principal’s Authority

(applicable for brokers/ intermediaries - a letter of appointment from the potential insured is required)
Transaction for which insurance cover is requested*

(state whether it is an equity investment; shareholder loan; commercial loan; loan guarantee; mobile asset; trade in goods/services on open account, leasing etc.):

3. Transaction / Investment Parameters
3.1 Details of Party to be Insured
Name & Country:*
Legal Form and Nature of Business*

(indicate whether natural person, private, public listed, sub-sovereign, parastatal, other; and state the nature of business)
3.2 Details of Risk Counterparty/ Project Enterprise
Name & Country:*
Legal Form and Nature of Business*

(indicate whether natural person, private, public listed, sub-sovereign, parastatal, or other [specify]; and state the nature of business):
Relationship with the Insured party

(indicate whether borrower, project enterprise, or other [specify]. Does the insured have any previous experience with the risk counterparty? If yes please provide a brief explanation):
3.3 Details of the Transaction/Project
Insured Transaction/Project (Brief description):
Value and Currency of Transaction/Project:

Transaction/Project Type

(state whether it is a supplier credit, buyer credit, supply agreement, leases agreement etc.):
(if applicable, please provide copy of contract/draft loan term sheet):
Terms and Method of Payment:
Transit Countries
(if applicable):
Specific Comments
(if necessary, please provide additional comments not captured in this enquiry form):
How did you get to know about ATI?

Insurance Enquiry

Step 1 of 4

Confidentiality / Authorisation for Limited Disclosure

Type of Cover