Application Insurance of Capital investment

Before answering these questions, please consult the explanatory notes at the end of this form.

Other application forms can be downloaded from: http://www.atradiusdutchstatebusiness (Use the correct application form for your transaction)
The processing of your application by Atradius: 1. After we have received your application, we will send you an acknowledgement of receipt. 2. As soon as we have the necessary information at our disposal, we will be able to process your application. 3 If the investment amount is EUR 10 million or more, we request you to complete questions 7d up to and including 7q and to provide required annexes. In some cases, we will also request you to complete these questions if the investment amount is below EUR 10 million. 4. While your application is being processed, we will keep you informed regularly about the current progress.

1. The Applicant
a. Name of the applicant, as listed in the Trade Register:
Business address (including post code):
Address for correspondence (including P.O. Box and post code):
Telephone:
Fax:
Contact person Mr/ Ms.:
Telephone / extension no. of contact person:
Position of contact person:
b. Group of which the applicant is part:
c. Legal form:
If the applicant is not a legal person, the name, address and nationality of the proprietors:
If the applicant is a legal person, the percentage of the share capital that is in Dutch ownership. %
d. Other documents that give evidence of the Dutch nature of the applicant:

(It is advisable to send with this form any information which you have about the business referred to below, e.g. annual reports, or

other information about its financial circumstances that you have in your possession)

2. The Beneficiary
Name of the business in which the investment is to be made:
Full address and country:
Date of establishment and objects:
Year:
Object:
How is the business managed? (See explanatory note 2d)
e. Who are the other investors and what are their respective percentages of the capital investment?
Name :	Country:	Percentage
f. Do you have existing capital investments in this business?	Yes No
What has been your experience of these capital investments?

3. The capital investment
a. Nature of the capital investment: (Money, goods or services)
b. Form of the capital investment: (See explanatory note 3b)
c. Purpose of the capital investment: (See explanatory note 3c)
d If the capital investment is in the form of goods, are they being manufactured by you? (if not, please explain)	Yes No
e. What is the importance of the proposed capital investment to the country in which the investment is to be made?

4. Amount of the capital investment
a. What is the amount of the proposed capital investment in :	€ Foreign currency :
b. Will titles and/or security be received in return for the capital investment? (See explanatory note 4b)	Yes No
Nominal value (if so, please state the nominal value)
c. Does the investment agreement provide for repayments and/or redemptions? (If so, please state the maximum percentages or amounts and the interest rate)	Yes No
d. What are the expected proceeds? (See explanatory note 4d)
e. How and when will the repayments and/or redemptions or the proceeds be determined or paid?

5. Investment dates
a. Start date of the investment :
b. Date investment completed :
c. Duration of the investment :	Maximum :
Or until :

6. Country of investment
a. Conditions of repayments and/or redemptions: (See explanatory note 6a)
b. Time taken to process transfer application: (See explanatory note 6b)
c. Has the government of the country of investment approved the investment?	Yes No
(If so, which document evidences this approval? Please attach a copy) (If not, why not?)
d. Description of the contracts: (See explanatory note 6d)
e. Does special legislation apply? (See explanatory note 6e) (If so, please attach a copy)	Yes No
Do provisions and/or government decisions apply? (If so, please attach a copy. See explanatory note 6f)	Yes No

7. Corporate Social Responsibility
I. Bribery
(see explanatory note 7a to c)
a. Are you aware that in connection with the capital investment to which this application relates any payment or donation has or will be given or offered; - any pledge has or will be made; - any service has or will be performed or offered; - any benefit of whatever nature (including intangible benefits and benefits in kind) has or will be awarded, pledged or offered, by you or by another person to persons who are in the public service of a foreign state or public international body, whether or not this is dependent on the fulfilment of a further condition or conditions, which payment, donation, pledge, service or benefit could be interpreted in such a way that bribery or attempted bribery has taken place or will take place, or at least that an attempt has or will be made in an improper manner to obtain a competitive advantage, a better negotiating position, more favourable contract terms, or any other benefit?	Yes No
Is your contract a subcontract linked to a main contract, concluded or to be concluded by your buyer with an end- user?	Yes No
If so, are you aware, that in connection with that main contract, bribery or an attempt thereto has taken place or will take place?	Yes No
b. Are you listed on one of the publicly available debarment lists of the following international financial institutions: World Bank Group, African Development Bank, Asian Development Bank, European Bank for Reconstruction and Development and the Inter American Development Bank? (See explanatory notes)	Yes No
c. Are you, or anyone acting on your behalf in connection with the transaction, currently under charge in a national court or, within a five-year period preceding the application, have you been convicted in a national court or been subject to equivalent administrative measures for violation of laws against bribery of foreign public officials of any country?	Yes No

II. Environmental and social aspects
Before answering these questions, please read point 3 on the cover page to determine if you need to complete this section. In case the contract price is less than EUR 10 million, but it concerns a sensitive sector, or the transaction, or project of which the transaction is a part of, is located in a sensitive area we will request you to complete these questions. (See explanatory notes for question 7d to q). If this is not the case, please continue with question 8.
d. Correct address, place and description of the investment location: (Please provide us with a detailed map of the location)
e. As or for what is the investment location currently used ?
Urban
Industrial
Agricultural
Greenfield
Other, please specify:
f. In which sector will the investment be made?
Mining, oil and gas exploration
Iron and steel
Petro-chemicals
Energy production and distribution
Land reclamation and dredging
Dams and hydro-electric power
Other infrastructure and civil engineering
Large-scale agri- or horticulture
Other sector, please provide details

g. What type of sensitive location could face an adverse environmental impact from the investment? (Please mark all relevant boxes)
Investment Location	Effect area
Semi-arid or desert margins
Tropical or sub-tropical rainforest
River deltas, coastal areas, mangroves or coral reefs
National parks
World Heritage List/World Biosphere Reserve areas
Rare/threatened species’ habitats
Areas of very high population density
Areas of archaeological significance
Areas with indigenous peoples
Other sensitive location, please provide details

Environmental and Social Impact Assessment
h. Does the investment have an analysis of its environmental and social effects and associated preventive measures, e.g. an Environmental Impact Assessment, an Environmental Impact Statement or Social Impact Assessment? (See explanatory notes)	Yes No (If yes, please provide a document written in English or Dutch)
i. If yes, what is the status of the impact assessment report:
- In progress
- Draft version available
- Approved by	(name organisation) (date)
And is the impact assessment public?	Yes No (If no, this could lead to a delay in your application)
j. Has a management plan been developed (ESMP) for the investment, covering measures to mitigate potential negative environmental and social impacts? (See explanatory note)	Yes No (If yes, please provide a document written in English or Dutch)
k. Will there be resettlement as a consequence of the investment?	Yes No

l. As far as you know does the capital investment involve, during the period of the capital investment: (See explanatory note 7l) child labour? compulsory labour? restrictions in freedom of association and collective bargaining? discrimination? (If one of these questions has been answered ‘Yes’, please explain)	Yes No Yes No Yes No Yes No
m. Does your transaction and/or the project apply applicable environmental standards and management systems (e.g. ISO 14001, VCA or OSHAS 18000)? If yes, please specify.	Yes No
n. What standards do the techniques used meet? Please give details. (e.g. Best Available Technique (BAT)).

Environmental and social legislation and standards
o. Which local and international environmental and social legislation and/or standards are applicable for the investment? Please specify and add an annex if needed.
p. Who is the competent authority that verifies whether the investment complies with the applicable legislation and/or standards? Please specify and add an annex if needed.
q. What kind of environmental permits are or will be granted? Please provide details permit name, competent authority and date the permit was or will be granted. If needed you may provide this information in an annex.

8. Cover required
Would you like to partially or fully transfer the portion not covered by Atradius (your own risk)? (If yes, which portion and to whom?)	Yes No
Which cover do you require? (you can tick one or more boxes)
Expropriation
War
Transfer risk
Breach of contract by a public party

9. Other particulars
The application concerns: A promise of cover (in case the investment has not yet commenced) An insurance policy (in case the investment has commenced) A pro-forma application to support an application of the financing bank
If we have already issued a promise of cover for this investment, what is the reference number of this promise of cover?. Will a bank offer financing to the beneficiary in relation to this investment? Is it the intention that this financing will be insured by way of a Financing Policy? (If yes, then the bank must submit an application with us as soon as possible) If information on a possible financing becomes known to you only at a later stage, then we request you to inform us without delay. (See also under Signature, third tiret) Yes No Yes No For this investment, has an application been made, or will be made, to the Dutch authorities for a grant, aid financing or any other subsidy, through which (part of) the investment will be paid? (If yes, for which part of the investment and what is the reference number? Yes No Amount: € Reference Number:
e. Are there any facts or circumstances about which information has not been requested specifically above, but that may be relevant to an assessment of the application? (If yes, please explain. See explanatory notes) Yes No

10. Signature
The undersigned declares: - that the questions in this form have been answered correctly and completely and that no circumstances of importance to Atradius have been concealed; the information provided in this form is a full and accurate picture of the risks environmental and social impact associated with the capital investment, as known to him/her at the time the application was submitted; - that he will notify Atradius without delay in writing of any fact or circumstances which become known to him after the submission of this application; that, if the State of the Netherlands is prepared to enter into an insurance contract and the investment contract has entered into force, he will accept the policy and will pay the premium for this; - that he has taken note of the OECD Guidelines for Multinational Enterprises and will endeavour to apply these in his business to the best of his ability; that in connection with the capital investment to which this application relates he will at all times refrain from bribery as referred to in question 7 of the application form and the explanatory note thereto and from inciting or being an accessory to such bribery;
Incomplete or inaccurate information in this form may result in a delay of processing the application. If, before issuing the policy, it appears that you were or should have been aware of not reported facts or circumstances which were relevant for the assessment of the application, this may result in a laps of entitlement to indemnity or reclamation of compensation paid.
Place/ Town :
Date :
Name :
Signature :
The officer who signs this application should be competent to commit the applicant to at least amounts of the same order of magnitude as the amount of the investment to be insured.
If your investment is classified as an A-project, the project as well as the environmental and social information or a summary of this will be made public at least 30 calendar days before the issuing of the policy.
If your application results in a policy being issued, Atradius will publish certain information about your investment on its website one month after the date of issue of the policy.(See explanatory note)

Explanatory notes to the questions on the application form entitled "Insurance of

Capital Investment"

Question 2d:	Supervisory Board, Management Board, Directors (specifying any other positions held by these directors).
Question 3c:	Participation in share capital, agreement granting rights and/or services, long-term loan.
Question 3d:	For example, the establishment or expansion of a factory, foundation or the improvement of an enterprise, stating where the goods, rights or services delivered will be located or used.
Question 4a:	Analysed by the nature of the capital investment (see 3a), including a description of the goods, services, etc. to be delivered.
Question 4b:	For example, shares, bonds, etc.
Question 4d:	For example, dividends, interest, salaries, wages or royalties.
Question 6a:	Which conditions apply regarding the repayment or redemption of the capital investment and payment of the proceeds in the country of investment?
Question 6b:	How much time do you estimate the authorities in the country of investment will need in order to process the application for the conversion of local currency into euros for the repayment or redemption of the capital investment and payment of the proceeds?
Question 6d:	Brief description of the contracts and other agreements between the government of the country of investment and the applicant, and/or with the business in which the investment is being made.
Question 6e:	For example, laws regarding new industrial establishments.
Question 6f.:	Are there any administrative provisions and/or government decisions that apply to the capital investment or to the business in which the capital investment is to be made?
Question 7a:	The State of the Netherlands will under no circumstances become involved in insuring capital investments which are associated with breaches of fundamental labour standards laid down in Treaties Nos. 29, 87, 98, 100, 105, 111, 138 and 182 of the General Conference of the International Labour Organisation (ILO), unless compliance is not possible as a result of legislation in the emerging market concerned. Well-founded suspicions that these fundamental labour standards are being or will be breached will also be regarded as grounds for rejecting the application. If there is uncertainty regarding the question of the extent to which the activities of the local business will breach one of these standards this must be explained in further detail by the applicant. A more detailed description of the four fundamental labour standards laid down in these treaties is available from Atradius. This is also available on the web site of the Ministry for Economic Affairs: http://www.oesorichtlijnen.nl
Question 7a, c	The State of the Netherlands will under no circumstances become involved in investments in which bribery has taken place, bribery being interpreted for this purpose in the broadest terms. The question includes a list of terms of bribery that is not exhaustive. Even if the bribery concerned is a form of bribery that is not listed explicitly, or if you have reasons to suspect that there may be question of such a form of bribery, you must declare this bribery in your answer. Please note that the question also relates to bribery (in the broadest terms) by persons other than the applicant and of persons other than the principal. In any case, you must explain an affirmative answer so that Atradius is able to consider whether to enter into an insurance contract with you. We would draw your attention to the fact that bribery of foreign officials is also expressly prohibited by sections 177 and 177a in conjunction with 178a of the Penal Code (Wetboek van Strafrecht). In the event that Atradius suspects that bribery has nevertheless taken place, Atradius reserves the right to report this suspicion to the Dutch investigative authorities.
Question 7b, c	One of the agreements within the OECD is the Convention on Combating Bribery of Foreign Public Officials in International Business Transactions. In this context Atradius has committed itself to ask these questions. If you have answered one of these question with “Yes” we will undertake enhanced due diligence.
International guidelines	The information provided for the review of environmental and social effects will be reviewed against national legislation of the country where the goods and/or services will be used and against international guidelines as laid down in the “Common Approaches” (OECD guidelines 12 June 2007) The “Common Approaches” protocol prescribes how applications should be classified and reviewed. The applied international guidelines are the relevant aspects of the ten World Bank Safeguard Policies (Safeguard Policies). For the private sector or non-recourse project finance cases the relevant aspects of all eight IFC Performance Standards, multilateral development bank or EU guidelines will be applied. In addition relevant aspects of any internationally recognised sector specific or issue specific standards can be applied for the transaction/project that are not addressed by the World Bank. A further explanation of Atradius Dutch State Business’ approach on CSR can be found in the CSR brochure: http://www.atradiusdutchstatebusiness.nl/dsben/csr/index.html
Question 7f:	This question refers to the sectors as listed in Annex 1 of the “Common Approaches”. NB Annex 1 is an illustrative list and therefore does not cover all sensitive sectors.
Question 7g:	Sensitive locations include national parks and other protected areas identified by national or international law, and other sensitive locations of international, national or regional importance, such as wetlands, forests with high biodiversity value, areas of archaeological or cultural significance, and areas of importance for indigenous peoples or other vulnerable groups (see “Common Approaches”, Annex 1 point 26).
Question 7h to j:	Environmental Impact Assessment (EIA): an environmental impact report drawn up by an independent internationally-recognised environmental consultant in accordance with international guidelines. Environmental Impact Statement (EIS): an environmental statement with commentary. This statement has to be prepared on the basis of research results and at least state in quantified terms what the environmental effects are, how long they are expected to last and the measures taken to mitigate the adverse effects. Social Impact Assessment (SIA): a social impact report drawn up by an independent internationally-recognised environmental consultant in accordance with international guidelines. Environmental & Social Management Plan (ESMP): a management plan (based on an EIA and SIA) drawn up by an independent internationally-recognised consultant concerning the implementation of measures to mitigate the negative environmental and social effects.
Question 7l:	In the application form questions are being asked about the four core labour standards: freedom of association and collective bargaining, elimination of forced and compulsory labour, elimination of discrimination in respect of employment and occupation and abolition of child labour. In the review of the transaction/project all ILO labour standards, in so far as relevant, will be reviewed. The other ILO labour standards are: disciplinary practices, health and safety, working hours, and remuneration. If a well-founded concern exists that the labour standards will be violated in the project the application will be rejected. This is the policy of the Dutch Government.
Signature:	The Government aims to promote socially responsible business practice and therefore asks businesses that make use of the capital investment reinsurance scheme (Regeling herverzekering investeringen / RHI) to issue a declaration of intent to apply the OECD Guidelines for Multinational Enterprises to the best of their ability. You can consult the OECD Guidelines via the Internet (www.oesorichtlijnen.nl). You can also request a copy of the guidelines from Atradius. Important information on the public nature of the information - If a transaction after receiving the form is classified as an A-project (a project with potential significant adverse impacts), the project information (project name, location, project description and contact details) will, a soon as a possible but at least 30 calendar days before the issuing of the policy, be made publicly available . Information on the environmental and social effects or a summary of this will also, a soon as a possible but at least 30 calendar days before the issuing of the policy, be made publicly. - Publication and release of aforementioned information to third parties is a requirement under the Dutch legislation and forms part of international agreements. - Only in exceptional cases, based on well-founded objections provided by you could information or parts of the information will not be published or its publication will be postponed. This is at our discretion. - Atradius could use the provided information to meet its reporting obligations following from national and international agreements. The information that Atradius will publish about your transaction once it is in effect will be: the country of investment, the name of the investor and any lender, a brief description of the investment, the maximum indemnification payable, the name of the company invested in, the results of any environmental impact assessment and any aid finance provided by the Government of the Netherlands. The period of one month after the issue of the policy set for publication of this information may only be deviated from in the case of very material interests, which shall be at the discretion of the State of the Netherlands.