Business Interruption Worksheet - Healthcare Business Interruption .xls by suchufp

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									                      Healthcare Business Interruption and Extra Expense Worksheet (12 month)
Subscriber

Location's Covered
     Please complete a separate form for each location requiring coverage or indicate entire enterprise
Business Interruption values are your projections for the upcoming year, determined by documenting gross earnings from the previous year and
anticipating earnings for the upcoming year. The form is broken down into sections; Income, Deductions, Payroll and continuing expenses to help
determine the 12 month Business Interruption Limit and Extra Expense.

Income provides space for you to capture all income which would cease if forced to shutdown operations. Record actual values in the first column
and projected values for the upcoming year in the second column. Examples of revenue typically not included are Fund Raising Proceeds or
funding unless they would be jeopardized by a shut-down. Research Grants and/or Contracts that are performance based and where funding would
be jeopardized by a delay in completion due to the loss of facilities, equipment and research results should be included in the revenue reported.


                                                                                                                   Actual       Estimated 12
                                                                                                              (past 12 months) month amount -
                                                                                                                                coming year
INCOME

1    Public or Government Funding                                                                             $              -   $                -
2    Client or Patient Service Revenue (Emergency, Inpatient and outpatient)                                  $              -   $                -
3    Third Party Utilization of Property and/or Services                                                      $              -   $                -
4    Ambulance Charges                                                                                        $              -   $                -
5    Cafeteria                                                                                                $              -   $                -
6    Commissions and rents from leased departments, operations or concessionaires                             $              -   $                -
7    Consulting Services                                                                                      $              -   $                -
8    Emergency Room Service                                                                                   $              -   $                -
9    Gift shops                                                                                               $              -   $                -
10   Laboratory Fees & Other Fees                                                                             $              -   $                -
11   Parking                                                                                                  $              -   $                -
12   Pharmacy (operated by you)                                                                               $              -   $                -
13   Rent                                                                                                     $              -   $                -
14   Research Grants and/or Contracts (see note above)                                                        $              -   $                -
15   Room & Board (Dormitory Fees and Meal Contracts)                                                         $              -   $                -
16   Telecommunications Satellite Educational Classes                                                         $              -   $                -
17   User Fees (Library/ Conferences)                                                                         $              -   $                -
18   Vending                                                                                                  $              -   $                -
19   Other Income Specific to Your Institution (do not include fundraising, donations or investment income)
     -                                                                                                        $              -   $                -
     -                                                                                                        $              -   $                -
     -                                                                                                        $              -   $                -


A    INCOME
      TOTAL INCOME                                                                                            $             -    $                -


DEDUCTIONS (All Operating Expenses that would Discontinue if the Facility Shutdown Operations)

1    Contractual Adjustments, Bad Debts and Collection Expenses                                               $              -   $                -
2    Cost of Energy / Utilities (Excess Minimum Demand Charges)                                               $              -   $                -
3    Cost of Materials and Supplies consumed directly supplying your services                                 $              -   $                -
4    Cost of Services Discontinued - Auxiliaries                                                              $              -   $                -
5    Cost of Services from Outsiders (not your employees) to resell, that do not continue under contract.     $              -   $                -
6    Other Discontinued Expenses                                                                              $              -   $                -
7    Other (describe)                                                                                         $              -   $                -
8                                                                                                             $              -   $                -


B    TOTAL DEDUCTIONS                                                                                         $0                 $0




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                            Healthcare Business Interruption and Extra Expense Worksheet (12 month)
REGULAR CONTINUING PAYROLL EXPENSE
   Officers and managers                                                                                                                                                     $                        -    $                           -
   Other continuing staff ( please attach a schedule listing positions)                                                                                                      $                        -    $                           -
OPTIONAL PAYROLL
   Selected number of months coverage                 (enter, 3, 6, 9 or 12 months)
   Selected optional coverage amount                                                                                                                                         $                        -    $                           -

C      TOTAL INSURED PAYROLL                                                                                                                                                 $                        -    $                           -


D      INSURABLE BUSINESS INTERRUPTION AMOUNT (Line A - Line B + C )                                                                                                         $                   -         $                   -

Extra Expense Coverage is intended to pay for expenses to help your organization operate as normally as possibly during a period of interruption. The largest expenses are rental and set-
up of temporary facilities. This guide outlines some of the potential costs you may incur in a 12 month period.

       EXTRA EXPENSE                                                  ( only complete this section if these values are to be included in total insured Limit)

1       Transportation expenses                                                                                                                                                                            $
2      Cost of moving to and from                                                                                                                                                                          $
3      Extra labor (overtime payroll and additional)                                                                                                                                                       $
4      Insurance expense at temporary location                                                                                                                                                             $
5      Preparation of temporary premises                                                                                                                                                                   $
6      Public service announcements                                                                                                                                                                        $
7      Purchases of goods and materials                                                                                                                                                                    $
8      Rental of temporary premises                                                                                                                                                                        $
9      Security and police services                                                                                                                                                                        $
10     Services purchased from others                                                                                                                                                                      $
11     Telephone and computer installations                                                                                                                                                                $
12     Utilities, heat, light, power, cable, water at temporary location                                                                                                                                   $
13     other (describe)                                                                                                                                                                                    $
                                _______________                                                                                                                                                            $
                                _______________                                                                                                                                                            $
                                _______________                                                                                                                                                            $

E      Total Extra Expenses to be insured                                                                                                                                                                  $                   -
Select only one of the following with an X
x
       Total Business Interruption (Maximum of 12 month recovery period)                                                                                                    (Line D)                        $                  -

       Total Extra Expense (Maximum of 12 month recovery period)                                                                                                            (Line E)                        $                  -

       Total Business Interruption and Extra Expense (Maximum of 12 month recovery period)                                                                                  (Line D + E)                    $                  -
                                                      I certify this is a true and correct report of values
                          You are hereby authorized to effect additional insurance based on the estimated values indicated (X) above




       Date                                                           Signature




                                                                      Print Name




                                                                      Official Title

Note: For business interruption to be considered an insured loss, there must be an insured claim/direct damage under the property section of the policy. For example, closure due to infectious disease would not be an insured
claim. Not included in this standard form, is a loss of income due to loss or damage at a key supplier, customer or referral source, or because of ordinance or law, royalties, leasehold interest or loss to personal property away
from the premises. Please refer to the policy wording for a complete description of coverage. This form is intended for an indemnity period or for recovery of 12 months.




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                                                 Healthcare Business Interruption - Rental Income (12 month)
Rental Income helps pay for the loss of rental or rental fees and continuing expenses

Subscriber

Location's Covered
                            Please complete a separate form for each location requiring coverage or indicate entire enterprise


RENTAL INCOME

              Expected Rental Value of unoccupied or unrented portions of property                                                   $   -

              Rental Income of rented portion of property according to leases and agreements in force                                $   -

                                                                                                                          SUBTOTAL   $   -

DEDUCTIONS

              Non Continuing Charges and Expenses                                                                                    $   -

RENTAL INCOME VALUE                                                                                                                  $   -

                                                    I certify this is a true and correct report of Rental Value
                             You are hereby authorized to effect additional insurance based on the estimated value indicated above



              Date                      Signature




                                        Print Name



                                        Official Title

								
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