Online Business Interruption Claim Form

    How To Fill In This Claim Form

    Please fill in this form to tell the Mutual about a claim. The form needs to be completed and signed by the Member named in the Schedule or, if the Member is a company or a partnership, by one of the directors or partners.

    Please fill in all relevant sections as fully as possible and attach additional pages if necessary together with copies of all documents, quotes, tax invoices and receipts to support your claim.

    Please contact us if you have any questions about your claim or filling in this form.

    Using Personal Information
    We may collect, use and share personal information from you, other people, businesses and organisations as part of our claims process. We will only keep personal information for as long as we need to use it. You can see how we use personal information, and the legal rights of people whose personal information we hold, in the privacy notice on our website If you would like us to send you a copy of our privacy notice please ask us.

    Printing the form

    If you wish to fill in this form by hand, just click the “Print Form” button below to print out this document.
    All completed forms can either be scanned and emailed to [email protected] or they can be posted to:
    The Retail Mutual,
    First Floor, Douglas House,
    Quarry Hill Road,
    TN9 2RH

    Print Form

    Otherwise please complete the form below and click submit.

    Permitted files JPG, PDF, PNG can not be larger then 10MBs per file

    A) Details of Membership

    B) Details of the event that led to the closure

    C) Claims for Business Interruption

    Business Interruption Loss

    Please fill in the dates of when your business was closed and subsequently re-opened, along with the total value of your loss. If your business has been closed on more than one occasion, then please fill in each line with the relevant dates and details of the net loss incurred for each period of closure.

    Date business closedDate Business re-openedNet loss (After having applied rate of gross profit and savings deducted from your turnover takings)

    Please include your takings for the dates the business was closed and the same period in the last 12-24 months. In addition please provide the 3 months' previous average daily takings before closure. We may make an allowance for saving during this period for such things as: heating, lighting, telephone, office stationery, office stationery costs and business expenses.

    D) Declaration

    As a Member / on behalf of the Member I confirm that the information I have given in this form is true and I understand that The Retail Mutual may exercise its discretion to provide cover

    Permitted files JPG, PDF, PNG can not be larger then 10MBs per file