Business Interruption Proof of Loss Form
Policy Holder Information
Business Name
Policy Number
Business Address
Contact Person
Phone Number
Email
Loss Details
Location of Loss (if different)
Date of Loss
Time of Loss
Cause of Loss
Description of Incident
Financial Information
Period of Interruption (Start Date)
Period of Interruption (End Date)
Amount Claimed
Basis of Calculation / Supporting Documents
Declaration
I/We declare that the information provided is true and correct to the best of my/our knowledge.
Signature
Date