Has your business suffered an economic loss due to COVID-19?*

Yes
No

Has COVID-19 been confirmed at your place of business?

Yes
No

Who was confirmed with COVID-19

On what date did this happen?

I am sorry but we cannot help you at this time. Please contact us at (239) 791-7950 if you have any questions,

Corporate Information

Legal Registered Name*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Annual Gross Revenue for the business:

Estimated lost revenues from COVID19:

Name of Authorized Business Representative*

First Last

Telephone Number*

EMAIL FOR LEGAL CORRESPONDENCE*

Business Interruption Insurance

Do you have Business Interruption Insurance?

Yes
No

Name of Insurance Provider

Name of Underwriter (If Known)

Have you made a claim with your insurance provider?

Yes
No

Event Cancellation Insurance

Do you have Event Cancellation Insurance?

Yes
No

Name of Insurance Provider

Name of Insurance Underwriter

Name of Cancelled Event

Please Provide a Description of the Event

Date of the Event

Date of Cancellation

Have you submitted a claim for this event with your insurance provider?

Yes
No

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