Quote Pharmaceutical

First Name
Last Name
Job Title
Company
Address
City
State
Zip Code
Country
Telephone
Fax
E-mail
Website

Business Description

How did you hear about Euler Hermes?

Please specify 'Other'

Your business is a:

If 'Other', please specify your business

Products/Services to be covered:

Numbers of years in business

Do you sell to countries outside of the U.S., Canada and Puerto Rico?

Yes
No

Domestic Sales (estimate for the next 12 months):

Average Terms of Payment

Longest Terms of Payment

Total Domestic Sales $ (U.S.)

Export Sales (estimate for the next 12 months):

Average Terms of Payment

Longest Terms of Payment

Total Export Sales $ (U.S.)

Your principal export markets

Latin America
Europe
Asia
Middle East/Africa

Distribution of Sales (estimate)

% of Manufacturers
% of Wholesalers
% of Distributers
% of Retailers

Total number of customers you sell to?

Please list your 3 key customers (company name and location)

Average A/R over the last year-

Domestic (U.S./Canada/Puerto Rico)

Export

Loss History (estimate)

Net Sales $(U.S.)-

2010 YTD:
2009:
2008:

Gross write-offs $(U.S.)-

2010 YTD:
2009:
2008:

Number of write-offs-

2010 YTD:
2009:
2008:

Largest single loss $(U.S.)-

2010 YTD:
2009:
2008: