Corporate Clients

Please complete all of the following fields.
**Denotes compulsory field

Name Of Business

Contact Name **

Contact Number **

Email **

Preferred contact method

Please select Phone Email

Trade

Are you a new or existing client?

Please select New Existing

If new, please advise how you got our name

Please select Websearch Recommendation Advertising Other

If existing, please enter your Client Reference if known

Do you currently have Care Home insurance for this business?

Please select Yes No

If yes, what is the renewal date?

D: M: Y:

What is the current annual premium that you pay?

What are you registered as?

Please select Care home only Care home with nursing Care home providing adult placement Care home not providing medicines or medical treatment (due to religious or ethical grounds) Care home including care for the young Care home including care for the alcohol dependent and drug dependent Care home including care for the mentally ill Other

If other, please specify

When was the business established (year)?

Type of care home residents that you have?

Old Age

Dementia

Physical Disability

Sensory Impairment

Learning Disability

Mental Health

Alcohol Dependency

Drug Dependency

Number of residents at care home

Age range of residents at care home (from / to)

Number of employees (full and part time)

Estimated Annual Employee Wage Roll

Current Annual Turnover

Are walls and roof of standard construction with a pitched roof?

Please select Yes No

Buildings

Computers

Contents

Frozen Food (Deterioration of Stock Cover)

Residents Personal Effects - per resident

Please select £250 £500 £1,000

Public Liability

Please select £2m £3m £5m £10m

Employers Liability

Please select £10m £20m £30m £50m

Business Interruption Cover

Business Interruption Cover - is cover required over 12 or 24 months?

Please select 12 Months 24 Months

Treatment Risk / Medical Malpractice

Please select 12 Months 24 Months

Loss of Registration

Please select Not Required £1m £2m £5m

Other (please specify)

Have you had any claims under this type of policy in the past 3 years?

Please select Yes No

If yes, please specify the number

Please select 1 2 3 4 5 6 7 8 9 10

Have any of these claims been settled for more than £2,500 (approx)?

Please select Yes No

Please provide any further details relating to your application (e.g. has property ever been affected by subsidence or underpinned? / is property on made up ground, near underground workings or near a cliff / have you ever had your request for insurance declined?)