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Please complete the following form about your company and your customers to receive your quote. We will contact you within 24 hours regarding the quote. If you prefer to discuss your credit insurance needs over the phone, please call us at 877-909-3224.

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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 ACI?

Please specify 'Other'

Your business is a:

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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
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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: