The Hanover Insurance Group and Citizens Insurance
Human Service Advantage Program
Business Income Worksheet
Named Insured:
________________________________________________________
Actual or Most
Recent Values
Year _______
Estimated Total
for next 12
Months _______
$ ________________
$_________________
D. Total Costs (sum of 1-7)
$ ________________
$_________________
E. Total Business Income Value (Revenue – Cost)
$ ________________
$_________________
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):
__________________________________
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
Recent Values
Year _______
Estimated Total
for next 12
Months _______
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)
$ ________________
$_________________
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 ___________________________________
__________________________________________
_____________________________
Name & Title of Individual
_____________________________
Signature
________________
Date