Business Interruption Proof of Loss Streamlined Business Interruption Proof of Loss 1 Business Overview2 Past Financials3 Projected COVID-19 Impacted Financials4 Checkout Name of Company InsuredAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance CarrierPolicy NumberNAIC codehttps://www.naics.com/search/Summary of Business OperationsSummary Description of RevenueSummary Description of Fixed ExpensesSummary Description of Changes to **Revenues** Due to COVID-19 and associated civil orders for distancing and business closuresSummary Description of Changes to **Expenses** Due to COVID-19 and associated civil orders for distancing and business closures Revenue Must have at least one of the following (more is better)Prior 3 monthsDecember 2019January 2020February 2020If you do not have this information, please enter in the following information:Year-ago monthMarch 2019And if you do not have this information, please enter in the following information:2019 Total YearExpenses Payroll - Must have one of Monthly or BiWeekly Payroll, but only oneMonthlyDecember 2019January 2020February 2020Bi-WeeklyLast payroll before March 20201 prior payroll2 prior payrollOperational Costs and Cost of Goods Sold Include all payments to vendors, suppliers, contractors not on payroll, and utilities.MonthlyDecember 2019January 2020February 2020If you do not have this information, please enter in the following information:March 2019Year-ago monthAnd if you do not have this information, please enter in the following information:2019 Total Year Revenue Provide your actual March 2020 revenue and projected April 2020 revenue, especially if you are anticipating it to be worse.Actual March 2020Projected April 2020ExpensesRent/MortgageActual March 2020Loan PaymentsActual March 2020PayrollTotal Projected Payroll **without** Business Interruption InsuranceInclude any additional employees required, overtime, hazard pay, etc.Total Projected Payroll **with** Business Interruption Insurance Claim PaymentIf you were to receive some assistance from Business Interruption Insurance, would you keep more employees on payroll? What would be your total payroll then?Operational Costs and Cost of Goods Sold Include all payments to vendors, suppliers, contractors not on payroll, and utilitiesActual March 2020MonthlyProjected April 2020New Expenses Due to COVID-19 and Civil Authority Orders Impacting Your BusinessExtra cleaning & disinfectant suppliesProjected April 2020Personal protective equipmentProjected April 2020Additional delivery costsProjected April 2020Remote work expensesProjected April 2020Spoiled inventory and disposal costsProjected April 2020OtherProjected April 2020Total - New Expenses Due to Covid-19 & Civil Authority Orders{Extra cleaning & disinfectant supplies:86} + {Personal protective equipment:90} + {Additional delivery costs:89} + {Remote work expenses:88} + {Spoiled inventory and disposal costs:87} + {Other:91}Business Interruption Claim Costs Third-Party Assistance, including the cost of the eRisk service, which may be reimbursable by your Insurance CarriereRisk Initial Proof of Loss ServiceOther third party assistanceTotal - Business Interruption Claim Costs{eRisk Initial Proof of Loss Service:83} + {Other third party assistance:84}Total - Expenses without COVID-19{Rent/Mortgage:100} + {Loan Payments:101} + {Total Projected Payroll **without** Business Interruption Insurance:102} + {Projected April 2020:105}Total - Expenses with COVID-19{Rent/Mortgage:100} + {Loan Payments:101} + {Total Projected Payroll **without** Business Interruption Insurance:102} + {Projected April 2020:105} + {Total - New Expenses Due to Covid-19 & Civil Authority Orders:92} + {Total - Business Interruption Claim Costs:82}Net Income without COVID-19{Projected April 2020:99} - {Total - Expenses without COVID-19:93}Net Income with COVID-19{Projected April 2020:99} - {Total - Expenses with COVID-19:94}Loss of Income{Net Income without COVID-19:95} - {Net Income with COVID-19:96} Credit Card* Card Details Cardholder Name Form SubmissionTotal $0.00 Disclaimer: The information contained in this Partial Proof of Loss was provided entirely by the policyholder and has not been audited by eRisk Solutions, which takes no responsibility for its accuracy
