Page 179 - claims information pack ebook_e

Example Claim Form
PART 2 Section D Claim Number (for internal use only)
Economic loss in the tourism sector
and other related businesses
Section D

14) Details of all other substitute income that you earned during the relevant period (e.g. resulting from other
paid activities including clean up response)

15) Other expenses incurred as a result of the incident

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.
Templates of similar tables and spreadsheets are available to download from the IOPC Funds website.
Whichever method you use, you must provide an explanation of the method you have used to calculate
the total amount of the claim.
34
Amount of loss during claim period (see table on page 33)
Item 11: Savings -

Item 12: Costs incurred to minimise losses +
Item 13: Other business income -
Item 14: Substitute income -
Item 15: Other expenses +

Total =

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.