Business Income Worksheet - Hanover Insurance



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The Hanover Insurance Group and Citizens Insurance

Human Service Advantage Program

|Business Income Worksheet |

Named Insured: ________________________________________________________

Actual or Most Estimated Total

Recent Values for next 12

Year _______ Months _______

A. Revenue Derived From the Following:

|1. Services Rendered including Residential or Outpatient Care | | |

|2. Grants & Independent Funding | | |

|3. Contracts for Services Rendered Including Mobile or Vocational Workforces | | |

|4. Thrift Stores and/or Associated Sales | | |

|Other Revenue (do not include donations/contributions), (describe): | | |

|_________________________________________ | | |

|_____________________________________________ | | |

B. Total Revenue (sum of 1-4) $ ________________ $_________________

C. Minus Costs:

|1. Bad Debt | | |

|2. Adjustments & Allowances for Government Agency Requirements | | |

|3. Costs of Goods Sold | | |

|4. Excluding or Limiting ‘ordinary payroll’ expense? | | |

|If ‘yes’, enter amount, if ‘no’, leave blank | | |

|5. Social Security, Unemployment Insurance and Other Charges allocated to | | |

|Ordinary Payroll | | |

|6. Light, Heat, and Power Expenses that do not continue under contract: | | |

|7. Other one-time, or non-reoccurring Expenses (describe): | | |

|__________________________________ | | |

D. Total Costs (sum of 1-7) $ ________________ $_________________

E. Total Business Income Value (Revenue – Cost) $ ________________ $_________________

|Extra Expense Worksheet |

Extra Expense Coverage provides additional coverage to help an organization continue their services despite damage to their property. This coverage is typically used to cover the costs associated with reducing the time it takes to reopen the organization due to property damage. For example, it may be used to move into a temporary space while work is being performed on the damaged property, or provide overtime wages to workers in order to decrease the time the property is closed.

Actual or Most Estimated Total

Recent Values for next 12

Year _______ Months _______

F. Extra Expense:

|1. Rental Fees for a Temporary Facility to Continue Operations | | |

|2. Moving Expenses (include transportation of clients if applicable) | | |

|3. Overtime and/or Special Compensation to Employees | | |

|4. Purchase of Goods & Materials to Continue Operations | | |

|5. Other ___________________________________ | | |

|__________________________________________ | | |

G. (Gross) Total Extra Expense (sum 1-5) $ ________________ $_________________

Minus expenses discontinued at the

Original location because of the loss ($ _______________) ($_______________)

H. Net Extra Expense $ ________________ $_________________

I. Total Insurable Business Income/Extra Expense $ ________________ $_________________

(E + H) Assume 100% Co-Insurance)

_____________________________ _____________________________ ________________

Name & Title of Individual Signature Date

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