Loss Of Revenue Statement Of Values

Profits Worksheet

Policy Number: / Broker:
Name of Insured:
For Location Address(es) or Scheduled Location No(s):

ALL ENTRIES TO BE ON AN ANNUAL BASIS

For each item applicable to your business or operation, enter:

  1. actual amounts over the most recent completed annual period; and
  2. projected amounts over the next annual period, commencing with the policy or renewal effective date.

Item Description

/ Actual Amounts For Annual Period:

From:

To:

/ Projected Amounts For Annual Period: (See Note 2)

From:

To:

NET PROFIT OR (LOSS) BEFORE TAXES / $ / $
PLUS CONTINUING OPERATING EXPENSES(See Note 1 below)
Advertising
Auditing and accounting fees
Data processing under contract
Delivery or other services under contract
Depreciation
Directors’ fees
Expenses of branch or local offices
Insurance premiums
Interest on debentures and bonds
Interest on mortgages and loans
Lighting, heating, power (at least to contract minimum)
Maintenance
Printing, stationery, postage, etc.
Pumping and ventilation
Rent
Royalties
Salaries and Wages (including employee benefits):
a)officers, executives, permanent staff
b)skilled employees whose services could not be dispensed with pending resumption of normal operations
Taxes
Telephone

- continued on reverse -

Item Description / Actual Amounts For Annual Period:

From:

To:

/ Projected Amounts For Annual Period: (See Note 2 below)

From:

To:

Travelling expenses
Upkeep of automobiles, etc.
(describe)
(describe)
(describe)
(describe)
Miscellaneous unspecified continuing operating expenses (not to exceed 5% of the total amount of specified continuing operating expenses)
Total amount of net profit (or loss) plus continuing operating expenses: / $ / $
Period of indemnity required (if less than or greater than 12 months):
Adjusted amount for an indemnity period that is less than or greater than 12 months:
For indemnity period less than 12 months:
= (Highest Monthly Revenue) X (Indemnity Period Number of Months)
For indemnity period greater than 12 months:
= (Average Monthly Revenue) X (Indemnity Period Number of Months) / Average or Highest Monthly Revenue:
$
X (Number of Months)
$
Minimum percentage (as shown on LOSS OF REVENUE COVERAGE SUMMARY):
Loss of Revenue Minimum Amount of Insurance / $

Ordinary Payroll Expense

Limited period ordinary payroll to be covered in days (typically 90 or 180 days) - if not to be insured for any period, indicate “not covered”. If to be insured for full amount over indemnity period, include as a “described” Standing Charge. / Days OR
Not Covered
Amount of ordinary payroll over period to be covered: / $

Note 1: Continuing operating expenses are those expense which in the event of a total interruption would not be eliminated or, in the event of a partial interruption would not be reduced in proportion to reduced revenue. Listed from items 1-21 are typical continuing operating expenses - others may be added as required. If your accounting methods make use of other terms to define continuing operating expenses, it is permissible to list them in that way.

Note 2: It is important to keep in mind that an interruption to the business arising out of a covered cause of loss could occur towards the end of the policy period. It may, therefore, be necessary to anticipate at least two years ahead when calculating the limit of coverage required.

Date completed: / Completed by:
Signature of Insured: / Date signed:

Statement of Values (10-04)Loss of Revenue Page 1 of 2