Page 173 - claims information pack ebook_e

Example Claim Form
PART 2 Section C Claim Number (for internal use only)
Economic loss in the fisheries, mariculture
and fish processing sectors
Section C

20) Details of any measures taken to prevent or minimise pure economic loss, including description and cost

21) Details of alternative income you earned during the time your business/operation was interrupted
(eg participation in cleaning operations, paid employment for other tasks, etc.)

Calculation of the total amount of the claim
You may wish to use the following table as an example of how to calculate the total amount of the claim.
Whichever method you use, you must provide an explanation of the method you have used to calculate the total
amount of the claim.
Item 17: Amount of loss during claim period

Item 18: Saved overheads or other normal variable costs -
28
Item 19: Saved labour costs -
Item 20: Costs incurred to minimise loss +

Item 21: Alternative income earned -
Total =

In order to calculate your loss:
The estimated loss of revenue is the difference between the revenue (excluding taxes) over the claim period and
the revenue that would have been obtained over the same period, if the incident had not occurred. The revenues
used in this calculation should be based on actual revenues attained in the business and NOT on an estimation
of future losses.

Additional Information:
Are the losses referred to in this claim insured in whole or in part? Yes No
If YES, please provide full details (name of insurance company, policy type, claim submitted, amount paid,
amount insured, any exclusions, etc.)

Provide details of any other claims for compensation you have made in connection with this incident.

Provide details of any other compensation or form of income you have received (e.g. state or regional
emergency funds, charitable donations, etc.) or you will receive in connection with this incident (name of
payer, amount received, etc.). If none, state NONE.

Have you submitted additional pages/documents to this claim form? Yes No
Please specify

Please submit all supporting documents and evidence for all costs incurred as detailed above.