Business Interruption Claim Notification Contact details Name Email Telephone Claim Details Policy number Date of loss Date of loss: Year Year20212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 Date of loss: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Date of loss: Day Day12345678910111213141516171819202122232425262728293031 Do you have an internal claims reference? Applicable if you are broker notifying a claim on behalf of an insured Question set 1. Business Name 2. Has there been any damage caused to your property by the COVID-19 virus? - Select -YesNo If yes, please provide details of that damage and what caused it. 3. Has there been an interruption to the business? - Select -YesNo If yes, please describe the nature of the interruption. 4. Not including the general closure and lockdown instructions issued by the Government on 27th March, has a public authority specifically instructed you to not use your business premises as a result of a case of COVID-19 at/in the vicinity of your business premises? - Select -YesNo If yes, please describe the specific restriction details. Please also provide a copy of correspondence from the Public Authority. 5. Has there been a specific incident within a one-mile radius? - Select -YesNo If yes, please provide details including details of how you became aware of this incident. Has access to premises been hindered or denied by a public authority as a result of this incident? - Select -YesNo If yes, did the denial of access / hindrance in access last more than 24 hours? - Select -YesNo 6. When did the interruption to your business begin? 6. When did the interruption to your business begin?: Year Year20212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 6. When did the interruption to your business begin?: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec 6. When did the interruption to your business begin?: Day Day12345678910111213141516171819202122232425262728293031 Is the interruption on-going? - Select -YesNo If no, when did the interruption end? If no, when did the interruption end?: Year Year20212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 If no, when did the interruption end?: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec If no, when did the interruption end?: Day Day12345678910111213141516171819202122232425262728293031 Has the business closed / continued to trade throughout this period? Please provide full details. 7. Is the business an “essential service” or “essential retail outlet” under the Health Act 1947 (Section 31A-Temporary Restrictions) (COVID-19) Regulations 2020? - Select -YesNo 8. Have you been able to use your premises for any purpose, and, if so, please provide details of any use and any relevant dates? 9. Does the business offer or provide services offsite or away from the insured premises? - Select -YesNo If yes, are those services continuing? - Select -YesNo 10. Are you operating from another location / are staff working remotely or from home? 11. If the premises was open would you be experiencing financial loss? - Select -YesNo Please provide details of the financial losses you have suffered as a result of the interruption to your business? (We will ask you for further information on your losses if cover has been triggered and we do not require you to submit management accounts etc. at this stage). If you have taken any steps to reduce your loss, please provide details. 12. Please provide any other information which you believe may be relevant to the claim or any additional information that you would like Hiscox to take into account in considering your claim. Please attach any additional documents here Unlimited number of files can be uploaded to this field. Maximum 10 MB per form. Allowed types: gif jpg png pdf doc docx ppt pptx xls xlsx.