Business Interruption Insurance
Proof of Loss
Policyholder Information
Business Name
Policy Number
Contact Person
Contact Phone/Email
Business Address
Loss Information
Date of Loss
Location of Loss
Description of Loss Event
Cause of Loss
Period of Interruption
Calculation of Loss
Description
Amount
Gross Earnings/Revenue Lost
Less: Expenses Saved
Additional Expenses Incurred
Total Claimed
Supporting Documentation
List documents provided (e.g., financial statements, invoices):
Additional Remarks
Authorized Signature
Date