Prospect House, 63 North Street, Sudbury, Suffolk CO10 1RE

Telephone: 01787 313133 Fax:01787 313656

Quotation form for Domiciliary Care & Home Support Agencies

Proposers Name

Address

Contact Name & Telephone Number

Date business established

Web site:

Email:

Business Description, please detail any additional activities the proposer may provide other than the following:

Personal Care – Bathing/Dressing – Administering of Prescribed/Non-Prescribed Medicines, Night Care, Carers Respite Service, Cleaning/Cooking/Household Tasks, Shopping & Laundry, Handyman & Gardening Services

  1. Will you accompany your clients on holiday ? YES/NO
  1. Anticipated Turnover for the coming year - £
  1. Do you work with Children ? - YES/NO – if yes please indicate percentage of turnover %
  1. Do you work with anyone who displays Challenging Behaviour ? - YES/NO – if yes please indicate percentage of turnover %
  1. If qualified Nursing care is provided please indicate the percentage of turnover %
  1. If care is provided into the following environments please provide an approximate percentage split:

Residential Care Homes%

Nursing Homes%

Hospitals%

  1. Are there any specific trading conditions when providing staff into the above environments which pass the onus of liability on ? YES/NO
  1. Are you registered with the Care Quality Commission ? YES/NO
  1. Name of existing Insurer & Renewal Date
  1. Has any Insurer declined your proposal, cancelled or refused to renew your policy, required an increased premium or imposed special terms ? YES/NO

If Yes please give details

  1. Claims History (Please supply full details)

12. Do you require any Buildings or Personal Accident cover YES/NO

Declaration

It is your duty to disclose all material facts to Underwriters. A material fact is one which may influence an Underwriter’s judgment in the consideration of your proposal. If you are in any doubt as to whether a fact is material you should disclose it.

Failure to disclose could prejudice your rights to recover in the event of a claim or allow Underwriters to void the policy.

I/We declare that the statements and particulars contained in the proposal are true and that I/we have not mis-stated or suppressed any material facts. I/We agree that this proposal together with any other information supplied by me/us shall form the basis of any contract of insurance effected thereon. I/We undertake to inform Underwriters of any material alteration to these facts occurring before completion of the contract of insurance. However, the duty to disclose material facts continues after the completion of the proposal form and throughout any period of insurance (and any extension thereto), upon which this

proposal form was used as the basis of the contract of insurance.

Signature

NAME:______

(Partner, Principal or Director)

Dated ______

If you feel that there is any further information which may assist us in obtaining your quotations please detail below