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?

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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

Do you have Event Cancellation Insurance?

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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?

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Business Interruption Insurance

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COVID-19 Business Impact Questionnaire

Corporate Information

Business Interruption Insurance

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