| Contact/Company Details |
|
Proposers Name
(incl. partners names if partnership): | | |
| Ltd. Company Name (if applicable): | | |
| Trading Status: | | |
| Care Home Trading Name: | | |
| Care Home Address: | | |
| Care Home Postcode: | | |
| Daytime Telephone No. | | |
| Mobile Telephone No. | | |
| E-Mail Address: | | |
| |
| General Information |
|
Please state the number of years you
have been trading at these premises: | | years |
Please state the number of years you
have been trading elsewhere (if applicable): | | years |
Is the business registered with the appropriate regulatory body?
(i.e. Care Quality Commission (England), Care and Social Services Inspectorate Wales,
or Scottish Commission for the Regulation of Care) | | No Yes |
If you have purchased an existing care home within the last 12
months, do you intend to predominantly continue with the existing staff? | | No Yes |
| If no, please provide details of the changes: | | |
| Proposers History |
Have you or any other partner or director,
been prosecuted under the Health & Safety Act? | | No Yes |
Have you or any other partner or director,
ever been declared bankrupt or insolvent? | | No Yes |
| Have you or any other partner or director, ever had any insurance declined, cancelled, refused, renewal refused or had any special terms applied by any insurer for the risks and/or covers proposed? | | No Yes |
| Details of Care Home |
| Is the home currently occupied? | | No Yes |
| Is the property currently trading as a care home? | | No Yes |
| Type of care home: | | Nursing Residential (Elderly) Children's |
| Details of Residents |
| Please state the minimum age of residents: | | |
Please state the maximum number of
residents that the home can accommodate: | | |
| Number of residents currently in the home: | | |
| Mental Illnesses |
Does the home provide residential accomodation for any
persons detained under the provisions of the Mental Health Act 1983? | | No Yes |
| If yes, give details including numbers, ages & cause of detention: | | |
| In respect of homes caring for residents with mental health problems or learning disabilities: |
(i) Explain the nature and severity
of the illnesses/disabilities catered for: | | |
(ii) Does the home accept clients with a history of
violence, aggression, sexual offences or arson? | | No Yes |
If yes, please provide details of they are
managed in order to protect other persons from injury: | | |
Have there been any incidents
of assault or abuse over the last 5 years? | | No Yes |
| If yes, please provide details: | | |
| Additional Risk Information |
| Does the home offer any surgery post operative care? | | No Yes |
| If yes, please state the percentage: | | % |
Please list arrangements for services made available
to residents in the home e.g. physiotherapy, etc. | | |
| Are any of the above services provided by you or your employees? | | No Yes |
| If yes, please provide details: | | |
If no, do you ensure that the practitioner holds
Public Liability and/or Professional Indemnity Insurance? | | No Yes |
| Do you provide Care in the Community? | | |
| Do you provide Sheltered Accomodation? | | |
| Do you provide Day Care? | | |
Do you provide any recreational facilities?
(e.g. swimming pools, jacuzzis, gymnasiums, etc.) | | |
| If yes to any of the above, please give details: | | |
| Are the residents/patients needs assessed and documented? | | No Yes |
| Are staff in attendance 24 hours a day? | | No Yes |
| Claims Experience |
Have you or any previous owner, director or partner of the
business suffered any loss, damage, injury or liability in the
last 5 years at these or any other premises whether insured or not? | | No Yes |
If yes, please provide details i.e. date of claim,
description of claim, amount claimed, etc.: | | |
| Health & Safety |
Does the home comply with Health and Safety,
COSHH and other environmental/health regulations? | | No Yes |
Does the home have a written Health and Safety
policy and are details of that policy passed to all employees? | | No Yes |
| Does the home have a specific action plan with regard to the clearing up of spillages of liquids and water, especially in the kitchen and bathroom environments, and warning notices to cordon off areas that are damp or wet be available and used? | | No Yes |
Are regulators fitted to restrict the temperature of hot water
and radiator surfaces/pipes to a maximum of 43 degrees centigrade? | | No Yes |
Is a pre-employment health questionnaire completed
by all prospective employees and, in particular,
specific enquiries about back problems made? | | No Yes |
Are all staff properly trained in lifting techniques and is the
training recorded in writing and does each member of staff
sign a statement to confirm that they have received such training? | | No Yes |
| Building Construction |
| Construction of the walls (e.g. brick, stone, etc.) | | |
| Construction of the roof (e.g. tile, slate, etc.) | |
(If flat, state if 'felt/bitumen' or 'concrete') |
| Percentage of flat roof (if applicable) | | % |
| Construction of floors (e.g. concrete, wood, mixed, etc.) | | |
| Approximately, what year was the property built? | | |
| Is the building purpose built or converted? | | Purpose Built Converted |
Is the property a grade listed building?
(e.g. grade I, II, II* etc.) | | |
Has any part of the property ever been
affected by any subsidence or flood damage? | | No Yes |
If yes, please provide details:
(e.g. type of damage, date of
damage, amount of damage, etc.) | | |
How far away is the property from the
nearest watercourse, river, canal, sea, etc.? | | |
| Fire Protection |
| Is a fire alarm installed? | | No Yes |
| If yes, please state type of fire alarm signalling: | | |
| |
| Property Cover |
|
| Level of Cover Required? |
(Excluding Terrorism Cover) |
| Do you wish to include terrorism cover? | No Yes |
| Buildings |
| Conservatory(s) Sum Insured (if applicable): | £ |
(Excluded unless stated above) |
Buildings Sum Insured including rebuilding,
architects' fees, removal of debris, etc.: | £ | |
| Do you wish to include cover for subsidence? | No Yes |
| Stock |
| Deterioration of Frozen Food Sum Insured: | £ | |
| Contents |
| Electronic Office Equipment Sum Insured: | £ | |
| Care Home Contents Sum Insured: | £ | |
| Residents Effects (£500, £750 or £1,000 per person): | £ | |
| Money |
| Money Sum Insured (during business hours / in transit): | £ | |
| Money Sum Insured (in a locked safe): | £ | |
| Goods In Transit |
| Goods In Transit Sum Insured: | £ | |
|
| Business Interruption |
|
If business interruption is required, please
state the Annual Gross Revenue of your business: | £ | |
| Please state the period of time you wish the cover to extend? | 12 months
24 months
36 months
(allow sufficient time for
rebuilding/refurbishing and
time to resume normal trading) |
| Is cover required for Loss of Registration Certificate? | No Yes |
| If yes, please state sum insured required: | £ | |
| Liability Cover |
|
| Public Liability: Yes No | Indemnity Required? |
| Malpractice Liability: Yes No | Indemnity Required? |
| Please state the total number of employee's: | |
| Please state the total annual wageroll (£'s): |
(Do not include any Domiciliary Care) |
| Number of qualified nurses (e.g. RGN, SEN, RMN, etc.): | |
| Number of auxiliaries: | |
| Does the business provide Domiciliary Care? | No Yes |
Please advise the type of domiciliary work carried out?
(e.g. 'meals on wheels', bathing, feeding, adminstering of drugs, etc.) | |
Please provide details of the number of
staff and the wageroll involved in domiciliary work: | |
|
| Legal Cover / Directors & Officers Insurance |
|
| Is Legal Expenses cover required? | No Yes |
| Is Directors & Officers insurance cover required? | No Yes |
| If yes, please state the limit of indemnity required: | |
|
| Other Information/Covers |
|
If there is any other type of information or covers
that you wish to include, please provide details: | |
|
| Details of Current / Previous Policies |
|
| Current annual premium: |
This may help us to get you a better quote |
| Current insurance provider: | |
| Renewal date/date cover required: | (dd/mm/yyyy) |
