Short Form Questionnaire
For Informational purposes only
Company Name
*
Role
*
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Rows
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
*
Rows
Range Credit Limits
# of Customers
Over $250k
$100-$250k
$50k-$100k
$25k-50k
$10-$25k
Under $10k
Debtor Aging as of:
*
*
Rows
Total Amount Outstanding
Current - Not yet due
1-30 days
31-60 days
61-90 days
Over 90 days
Accounts receivable balances at:
Rows
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).
Rows
Buyers
Buyers
∙
∙
∙
∙
∙
∙
∙
∙
∙
∙
Breakdown of Sales per Country
Rows
Country
Annual Sales
No. of Buyers
1.
2.
3.
4.
5.
6.
7.
Applicant Signature:
*
Date:
*
Sales Agent Name
*
Submit
Should be Empty: