Short Form Questionnaire
For Informational purposes only
Company Name*
Role*
Name*
First Name Last Name
Phone Number*
E-mail*
Address*
Street Address
Street Address Line 2
City State
Zip Code
What products/service do you sell ?*
To what market sector do you sell ?*
What are your standard Terms of Payment*
Do you agree with longer terms (If yes, show the maximum terms)*
Projected "Insured" Sales: (Please exclude any inter-company sales and letter of credit, or otherwise secured, sales from this figure)*

Insurable Sales

	Current Year to date	Calendar Year 2015	Calendar Year 2014	Calendar Year 2013
Period (indicate if different than the above headings)
Insurable Sales
Total Value of all Sales
Largest Bad Debt
Number of Losses

Buyer Breakdown*
Range Credit Limits # of Customers
Over $250k
$100-$250k
$50k-$100k
$25k-50k
$10-$25k
Under $10k
Debtor Aging as of:*
*
Total Amount Outstanding
Current - Not yet due
1-30 days
31-60 days
61-90 days
Over 90 days
Accounts receivable balances at:
Date Amount
Quarter Ending
Quarter Ending
Quarter Ending
Quarter Ending
Average number of days for which sales are not outstanding (from invoice date):*
List your top 20 buyers, including their legal name, complete address along the with requested credit limit (this limit should be the maximum exposure you have to this customer at any one time).
Buyers Buyers
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Breakdown of Sales per Country
Country Annual Sales No. of Buyers
1.
2.
3.
4.
5.
6.
7.
Applicant Signature:*
Date:*
Sales Agent Name*
Should be Empty: