Proposer's Name
Contact Name

Address
Postcode		Telephone
		Email

Business Description
No of Years In Business					Number of Employees
Renewal Date					Renewal Premium
Claims Experience
Date			Cause				Amount
Resident Categories			Number of Beds Registered For					Min Age of Resident Accepted
Care for the elderly including nursing
Care for the elderly excluding nursing
Others please describe
Are drugs administered other than as prescribed by the residents GP?
How many beds is the home registered for?
Do you provide care for persons with learning disabilities or detained under the mental health act?								Please Choose No Yes
Do you provide day care at the care home?								Please Choose No Yes
if yes how many day care places are provided?
What proportion of the staff are qualified to NVQ level 2?								%
Do you have a documented MRSA procedure?								Please Choose No Yes
The Premises
-Walls - Brick Brick/Steel Steel Wood Concrete Other - Roof - Slate Steel Concrete Timber/Felt Other - Floors - Concrete Stone Wood Other - Heating - Gas CH Electric Oil Portable Heaters None
- Electrics Checked - Less than 12 months Less than 3 years Less than 5 Years Other - Intruder Alarm - BT Redcare Digital Commmunicator Bells Only None - Alarm Maintained - Yes No - Other Occupants - Yes No
Other occupants		No Yes				if yes
Approved Alarm		No Yes				Signaling			None Bells Only Digicom Redcare
Sums Insured
Buildings including all non-combustible outbuildings. Rebuild Cost								£
Stock of consumables								£
Contents (ex Computers) all business contents excluding the following.								£
Computer Equipment								£
Residents Effects sum insured per resident								£
Deterioration of Frozen Stock								£
Household contents sum insured for proprietor or manager.								£
Personal possessions away from the home for proprietor or manager.								£
Business Interruption Estimated Gross Revenue for next 12 months								£
Business Interruption Indemnity Period								12 months 18 Months 24 Months 36 Months
Is cover required for provision of meals on wheels or other domiciliary care services away from the home?								Please Choose No Yes
				Turnover from this activity				Number of hours per week.
Meals on Wheels
Home Assistance such as bathing, feeding and toilet
Offering advice and emotional and psychological support
Clerical Wages				Number of Staff				£
All Other Employee Wages				Number of Staff				£
Manual Work Away Wages				Number of Staff				£
Goods in Transit maximum sum insured per vehicle								£
All Risks
Description of Items			Europe or Worldwide					Sum Insured
			Europe Worldwide
			Europe Worldwide
			Europe Worldwide
			Europe Worldwide
			Europe Worldwide
Legal Expenses								No Yes
Address of Property if different
Residual Computer Breakdown (additional costs)								£ Nil £20,000 £30,000 £40,000 £50,000 £100,000
Has there ever been any opposition to your registration certificate?								Please Choose No Yes
Please provide full details of any other requirements you may have or of any information that you feel is important to the consideration of this insurance.