What is required to start a claim?

Provide immediate written notice to your insurer with the incident date, policy number, and brief description. Follow insurer instructions for submitting a detailed proof of loss with financial exhibits.

Can I submit the form electronically?

Yes, most insurers accept electronic submission. Electronic signatures are legally binding under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met.

Which supporting documents are essential?

Include pre-loss and post-loss financial statements, payroll records, sales journals, supplier interruption notices, and invoices for extra expenses. Missing documents commonly trigger audits or request for supplements.

Who may sign the form?

An authorized officer, owner, or person named in the policy should sign. Signatures by unauthorized individuals can invalidate the claim submission and require re-execution.

Is notarization required?

Not typically required for standard claim forms, but affidavits or POAs attached to a claim may require notarization or witnesses depending on state rules; consult the insurer or state notary guidelines.

How long until a decision is made?

Processing times vary by insurer and complexity; providing complete documentation up front typically shortens review time, while audits or forensic accounting can extend resolution by weeks or months.

Electronic Signature
Templates
Miscellaneous
Business Interruption Form

Business Interruption Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

BUSINESS INTERRUPTION FORM

Parties

Claimant Name:

Claimant Business Name Payor / Recipient Name Payor Contact

Recitals

WHEREAS, Claimant conducts and operates a business described above and seeks compensation or agreement for loss of business income and extra expenses resulting from a discrete interruption event; and

WHEREAS, Payor has agreed to evaluate, adjust or make payment for measurable business interruption losses upon satisfactory submission of supporting documentation and this duly executed form; and

WHEREAS, the parties intend by this form to set forth the facts, the required supporting documentation and the agreement terms that will govern the restoration, mitigation and payment of interruption losses.

Incident Details

Date of Interruption: Time of Interruption:

Location of Incident Describe the incident and how it caused interruption Primary Cause (select all that apply)

Fire Flood / Water Damage Supply Chain Disruption Public Health / Pandemic Other:

Operations Impact

Estimated Duration of Interruption:

Estimated Lost Revenue Estimated Extra Expenses Incurred Mitigation Efforts Taken

Operations Resumed: Yes If resumed, Date Resumed:

Scope of Work

The parties agree that scope of work shall include assessment, mitigation, restoration, and/or temporary replacement services as required to return the business to materially equivalent pre-loss operations. The below description identifies the anticipated work for which compensation is sought.

Detailed Scope of Work

Payment Terms

Agreed Payment Amount:

Payment Schedule / Method

Late Payment Fee: Payment Due Within (days):

Banking / Payment Instructions

Supporting Documentation

Documents Provided (check all that apply):

Financial Statements Tax Returns Invoices / Sales Records Photographs of Loss Relevant Contracts

Term and Termination

Effective Start Date: Termination / End Date:

Either party may terminate this agreement for material breach if such breach is not cured within days after written notice. Termination does not affect obligations that accrued prior to termination, including payment for completed work and obligations to preserve and produce records.

Confidentiality

The parties agree that all non-public financial information, estimates of loss, and supporting documents submitted pursuant to this form shall be treated as confidential and used solely for the purpose of adjusting, negotiating and effectuating payment of the claimed interruption losses. Confidential materials shall not be disclosed except where required by law, court order, or with prior written consent of the disclosing party.

I acknowledge and agree to the confidentiality obligations set forth above.

Governing Law; Venue

This form and any agreement arising from it shall be governed by and construed in accordance with the laws of the state identified below, without regard to conflict of law principles. The parties submit to the exclusive jurisdiction and venue of the courts located in the selected jurisdiction for resolution of disputes.

Governing Law State Preferred Venue (County/City)

Entire Agreement

This form, together with the documents expressly incorporated and any duly executed payment schedule, constitutes the entire agreement between the parties with respect to payment and adjustment of business interruption losses. No prior or contemporaneous oral or written statements shall modify this agreement except by a written amendment signed by authorized representatives of both parties.

Certification

The undersigned certifies that the information provided in this Business Interruption Form and in any attached supporting documentation is true, accurate and complete to the best of their knowledge. The undersigned acknowledges that knowingly submitting false information for the purpose of obtaining payment or benefits may subject the signer to civil and criminal liability under applicable law.

Signature Authorization (Name and Title)

Claimant:

By:

Date:

Payor:

By:

Date:

What the Business Interruption Form Is and when it applies

A Business Interruption Form is a structured claim or reporting document used to notify an insurer or lender that a covered event has disrupted normal business operations and caused loss of income or increased operating expenses. The form collects identifying details, the period of interruption, quantification of lost revenue and extra expenses, supporting documentation (financial statements, payroll records, supplier contracts), and a claimant signature. Insurers use the form to assess coverage, request additional proof, and calculate indemnity under a policy's business interruption or contingent business interruption provisions.

Why a clear Business Interruption Form matters

Accurate, complete forms speed claim evaluation, reduce follow-up requests, and improve the likelihood of a timely indemnity determination by the insurer.

Who commonly completes or receives this form

The Business Interruption Form is completed by business owners, risk managers, brokers, or authorized financial officers when claiming lost income or extra expenses after a covered event.

Small business owners preparing a first-party insurance claim for lost revenue.
Risk managers and insurance brokers consolidating loss data for multi-location incidents.
CFOs or accountants submitting audited revenue schedules and payroll proofs.

Recipients typically include the insurer claims team, third-party adjusters, and any lenders or investors listed on the policy who require notice.

Essential sections to include in a professional Business Interruption Form

A complete form separates identification, loss period, financial quantification, extra expense listing, supporting exhibits, and certification/signature fields so reviewers can validate and calculate entitlement efficiently.

Claim Header

Insured name, policy number, contact details, and claimant role so the insurer can confirm coverage and reach the correct representative.

Loss Period

Start and end dates of the interruption, stated as MM/DD/YYYY, with the date business operations were first impacted and date of expected recovery.

Revenue Schedule

Line-item pre-loss and actual revenue schedules, typically monthly, with calculation showing lost gross profit or net income using the policy formula.

Extra Expenses

Itemized extraordinary costs incurred to avoid or reduce suspension of operations, supported by invoices, contracts, and payment records.

Supporting Exhibits

Financial statements, payroll reports, sales journals, supplier interruption notices, and any municipality or governmental orders affecting operations.

Certification

Signature block, printed name, title, date, and statement attesting to the truthfulness and accuracy of the information provided.

Step-by-step: Completing the Business Interruption Form

Follow these steps in order to prepare a complete, auditable claim package for your insurer or adjuster.

01

Gather documents: Collect financial statements, payroll, invoices, and contracts supporting revenue and extra expenses.
02

Complete header: Enter insured name, policy number, and contact information exactly as on file.
03

Quantify loss: Populate monthly revenue comparison and calculate lost gross profit or net income per policy formula.
04

Sign and submit: Sign, date, and provide attachments to insurer through the preferred claims channel.

Typical claims routing and review process

Understanding the typical flow helps you provide required items at each step and reduces processing delays.

Submission: Claim submitted to insurer or broker with form and supporting exhibits.
Acknowledgement: Insurer issues claim number and may request additional documentation.
Assessment: Adjuster reviews proofs, may audit records, and calculates payable amount.
Resolution: Payment or denial is issued with explanation and any appeal instructions.

Common digital workflow settings for online submission

Configure submission settings to control signer authentication, document retention, and notification behavior when filing electronically.

Field	Configuration
Signer Order	Define sequence: claimant → broker → insurer
Authentication	Email + SMS code or ID verification for higher confidence
Expiration	Set link expiry (e.g., 30 days) to maintain control
Attachment Rules	Allow PDF, DOCX, JPG; limit size per file

Options for electronic submission and platform compatibility

Use an eSubmission platform that supports common file formats and audit trails to preserve evidence of who signed and when.

File Types: PDF, DOCX, XLSX supported
Integrations: Salesforce, NetSuite, Google Workspace supported
Security: TLS in transit, AES-256 at rest

Platforms that capture timestamps, IPs, and an audit trail meet the ESIGN/UETA four-part validity test and simplify later proof of submission.

Typical timing expectations and policy-driven deadlines

Many policies require prompt notice and specific proof deadlines; follow the policy language and insurer instructions to preserve coverage.

Notify Insurer Promptly:

Provide initial notice as soon as practical per policy conditions.

Proof of Loss Deadline:

Submit detailed proof within the period stated in the policy, often 60–90 days.

Supplemental Docs:

Provide requested financial backups promptly to avoid delays.

Tax Reporting:

Document recoveries appropriately in tax returns per IRS guidance.

Appeal Periods:

Insurer denial letters typically state appeal windows and required steps.

Key milestones from incident to claim resolution

A clear timeline helps coordinate evidence collection, adjuster interaction, and internal approvals for quicker settlement.

01

Incident Occurs

Record date and immediate operational impacts for the loss file.

02

Initial Notice

Send prompt written notice to insurer per policy duty to notify.

03

Proof Submission

Assemble and submit financial schedules and supporting exhibits.

04

Adjuster Review

Respond to inquiries and provide access for any audits.

Common mistakes that delay Business Interruption claims

Incomplete revenue schedules: missing pre-loss comparatives or inconsistent accounting period definitions generate requests for clarification and delay payments.
Unclear loss period dates: failing to specify exact start and end dates causes disagreement on the covered indemnity period and multiplier application.
Insufficient supporting documents: submitting summary numbers without invoices, bank statements, or payroll records often leads to a formal audit.
Wrong signer or authorization: claims signed by unauthorized persons trigger re-submission and verification, extending processing time.

Security and compliance items to preserve evidentiary value

Encryption: TLS 1.2/1.3

Data at Rest: AES-256

Audit Trail: Timestamped action logs

Certifications: SOC 2 Type II

Regulatory: ESIGN and UETA compliant

Health Data: HIPAA available with BAA

Penalties and risks of filing incorrect or late information

Claim Forfeiture: Late notice may risk coverage denial under policy terms

1099 Penalties: $60–$330 per form under IRC §6721

I-9 Exposure: $281–$2,789 per violation (if employment records involved)

Intentional Misstatement: May lead to denial and potential fraud allegations

Contract Breach: Missing lender notice provisions can trigger default remedies

Audit Costs: Additional third-party audits or forensic reviews increase costs

Representative eSignature vendor pricing and feature summary

The table compares starting price and common feature availability across vendors; signNow is listed first per comparison conventions.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	Yes, 7-day trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Frequently asked questions about the Business Interruption Form

Answers to common questions about completion, eSigning, supporting documents, and timing to help avoid delays.

Need help? Contact support

What is required to start a claim?
Provide immediate written notice to your insurer with the incident date, policy number, and brief description. Follow insurer instructions for submitting a detailed proof of loss with financial exhibits.
Can I submit the form electronically?
Yes, most insurers accept electronic submission. Electronic signatures are legally binding under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met.
Which supporting documents are essential?
Include pre-loss and post-loss financial statements, payroll records, sales journals, supplier interruption notices, and invoices for extra expenses. Missing documents commonly trigger audits or request for supplements.
Who may sign the form?
An authorized officer, owner, or person named in the policy should sign. Signatures by unauthorized individuals can invalidate the claim submission and require re-execution.
Is notarization required?
Not typically required for standard claim forms, but affidavits or POAs attached to a claim may require notarization or witnesses depending on state rules; consult the insurer or state notary guidelines.
How long until a decision is made?
Processing times vary by insurer and complexity; providing complete documentation up front typically shortens review time, while audits or forensic accounting can extend resolution by weeks or months.

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