Business Interruption Property Damage Claim Form
Policyholder Information
Business Name
Policy Number
Contact Person
Phone Number
Email Address
Business Address
Incident Details
Date of Incident
Time of Incident
Location of Incident
Description of Incident
Authorities Notified (If any)
Property Damage
Description of Property Damaged
Estimated Cost of Repair/Replacement
Has Repair/Replacement Started?
Business Interruption
Period of Interruption - From
Period of Interruption - To
Details of Business Interruption
Estimated Financial Loss
Supporting Documents
List Documents Attached
Declaration
Declaration / Comments
Signed By
Date