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

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

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Who was confirmed with COVID-19

On what date did this happen?

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Annual Gross Revenue for the business:

Estimated lost revenues from COVID19:

Name of Authorized Business Representative*

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EMAIL FOR LEGAL CORRESPONDENCE*

Business Interruption Insurance

Do you have Business Interruption Insurance?

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Name of Insurance Provider

Name of Underwriter (If Known)

Have you made a claim with your insurance provider?

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Event Cancellation Insurance

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Name of Cancelled Event

Please Provide a Description of the Event

Date of the Event

Date of Cancellation

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