Business Report Worksheet by gxt80721

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									  Business Income Report/Worksheet
  (Non-Manufacturing)

  Named Insured: ___________________________________________________
  Location: ________________________________________________________

Coinsurance % to be shown on the policy Declarations: ____%
                                                                         Column #1:           Column # 2:
Coverage Form: ____ALS _____ MPI            ____ Coins Form            Actual Amounts          Estimated
                                                                         for Prior 12       Amounts for 12
                 ____/month Monthly Limit of Indemnity
                                                                        Month Period         Month Period
100% Payroll Included:       ___YES      ____ NO                       Ending 20_____       Ending 20_____
1. Total annual net sales from Merchandising or Non-
   Merchandising Operations, (Gross Sales less discounts,              $                    $
   returns, bad accounts and prepaid freight, if included in sales):

2. Add other earnings from your business operations (not               $                    $
   investment income or rents from other properties):
3. Total: (add lines 1 and 2)                                          $                    $
4. Deduct cost of merchandise sold including packaging                 $                    $
   material:
5. Deduct cost of materials and supplies consumed directly in
                                                                       $                    $
   supplying the service(s) sold by the insured:
6. Deduct service(s) purchased from outsides (not employees of
                                                                       $                    $
   the insured) for resale which do not continue under contract:
7. Deduct power, heat and refrigeration expenses that do not
   continue under contract if Power, Heat and Refrigeration            $                    $
   Deduction endorsement is attached to policy:
8. Total Deductions (add lines 4, 5, 6, & 7)                           $                    $
9. Total Earnings (line 3 minus line 8):                               $                    $
10. Deduct ordinary payroll expenses if written with Ordinary
                                                                       $                    $
    Payroll Exclusion endorsement:
11: Total (line 9 minus line10):                                       $                    $

12. Amount of insurance required (multiply the amount on line 11
                                                                       $                    $
    by the coinsurance percentage specified above):


                  “I certify that this is a true and correct report of values as required
                   under this policy for the 12 months ending                          .”

Insured’s Signature:                                                       Date:________________________

Print Name:                                                                _____________________________

Title:                                                                     _____________________________

  GECU 124 (10 01)
1)

								
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