Fillable CP Business Income Worksheet (Kinsale Insurance)

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CP Business Income Worksheet (Kinsale Insurance)

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Page 1 of 6
BUSINESS INCOME REPORT/WORKSHEET
Named Insured:
New: Yes No
Renewal: Yes No Policy Number:
Effective Date:
12-Month Period
Estimated For 12-Month Period
Ending:
Beginning:
Income And Expenses
Manufacturing
Non-
Manufacturing
Manufacturing
Non-
Manufacturing
A.
Gross Sales
$
$
$
$
B.
Deduct:
Finished Stock Inventory
(at sales value) At Beginning
–
–
C.
Add:
Finished Stock Inventory
(at sales value) At End
+
+
D.
Gross Sales Value Of
Production
$
$
E.
Deduct:
Prepaid Freight – Outgoing
–
–
–
–
Returns And Allowances
–
–
–
–
Discounts
–
–
–
–
Bad Debts
–
–
–
–
Collection Expenses
–
–
–
–
F.
Net Sales
$
$
Net Sales Value Of
Production
$
$
G.
Add:
Other Earnings From Your
Business Operations (not
investment income or rents
from other properties):
Commissions Or Rents
+
+
+
+
Cash Discounts Received
+
+
+
+
Other
+
+
+
+
H.
Total Revenues
$
$
$
$
SECTION A: GENERAL INFORMATION
SECTION B: BUSINESS INCOME REPORT/WORKSHEET FINANCIAL ANALYSIS
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
12-Month Period
Estimated For 12-Month Period
Ending:
Beginning:
Income And Expenses
Manufacturing
Non-
Manufacturing
Manufacturing
Non-
Manufacturing
Total Revenues (Line H. from
previous page)
$
$
$
$
I.
Deduct:
Cost Of Goods Sold (See page 5
for instructions.)
–
–
–
–
Cost Of Services Purchased
From Outsiders (not your
employees) To Resell, That
Do Not Continue Under
Contract
–
–
–
–
Power, Heat And
Refrigeration Expenses That
Do Not Continue Under
Contract (if CP 15 11 is
attached)
–
–
All Payroll Expenses
Or The Amount Of Payroll
Expense Excluded
(if CP 15 10 is attached)
–
–
–
–
Special Deductions For
Mining Properties (See
page 6 for instructions.)
–
–
–
–
J.1.
Business Income Exposure
For 12 Months
$
$
$
$
J.2.
Combined (firms engaged in
manufacturing and non-
manufacturing operations)
$
$
The Figures In J.1. Or J.2.
Represent 100% Of Your
Actual And Estimated
Business Income Exposure
For 12 Months.
Page 3 of 6
12-Month Period
Estimated For 12-Month Period
Ending:
Beginning:
Income And Expenses
Manufacturing
Non-
Manufacturing
Manufacturing
Non-
Manufacturing
K.
Additional Expenses:
1.
Extra Expenses – Form CP
00 30 Only (expenses
incurred to
avoid or minimize
suspension of business
and to continue
operations)
$
$
2.
Extended Business
Income and Extended
Period Of Indemnity – Form
CP 00 30 Or CP 00 32 (loss
of Business Income
following resumption of
operations for up to 60
days or the number of days
selected under Extended
Period Of Indemnity
option)
+
+
3.
Combined (all amounts in
K.1. and K.2.)
$
"Estimated" Column
L.
Total Of J. And K.
$
The figure in L. represents 100% of your estimated Business Income exposure for 12 months, and additional expenses.
Page 4 of 6
12-Month Period Ending:
Estimated For 12-Month Period
Beginning:
Calculation Of Cost Of
Goods Sold
Manufacturing
Non-
Manufacturing
Manufacturing
Non-
Manufacturing
Inventory At Beginning Of Year
(including raw material and stock
in process, but not finished stock,
for manufacturing risks)
$
$
$
$
Add: The Following Purchase Costs:
Cost Of Raw Stock (including
transportation charges)
+
+
Cost Of Factory Supplies
Consumed
+
+
Cost Of Merchandise Sold
Including Transportation Charges
(for manufacturing risks, means
cost of merchandise sold but not
manufactured by you)
+
+
+
+
Cost Of Other Supplies Consumed
(including transportation charges)
+
+
+
+
Cost Of Goods Available For Sale
$
$
$
$
Deduct: Inventory At End Of Year
(including raw material and stock
in process, but not finished stock,
for manufacturing risks)
–
–
–
–
Cost Of Goods Sold (Enter this
figure in Item I. on page 2.)
$
$
$
$
Calculation Of Special Deductions – Mining Properties
12-Month Period
Estimated For 12-Month Period
Ending:
Beginning:
Royalties, Unless Specifically
Included In Coverage
$
$
Actual Depletion, Commonly Known
As Unit Or Cost Depletion
(not percentage depletion)
+
+
Welfare And Retirement Fund
Charges Based On Tonnage
+
+
Hired Trucks
+
+
Enter This Figure In Item I. On
Page 2.
$
$
SECTION C: SUPPLEMENTARY INFORMATION
Page 5 of 6
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some states, any person who knowingly, and with intent to defraud any insurance company or other person, files an
application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for
the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits
a fraudulent insurance act, which is a crime.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact
material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application
or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application
for insurance or statement of a claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Page 6 of 6
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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CP Business Income Worksheet (Kinsale Insurance)

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Completed 18 July 2020

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