Nursing
& Care Home Insurance - Quotation Request
Proposer's name
E-mail address
Trading name
Address to be insured
Postcode
Contact Name
Correspondence address (if different from above)
Postcode
Telephone No
Fax No (optional)
About
the business
Registration under the Registered Home Act 1984. Please check
which of the following categories apply
Small Homes (Amendment Act) 1991
Registered: Solely under part 1
Dual-Registered
Registered: Solely under part 2
If the home is subject to any other type of registration
please specify
This question is for For Homes in Scotland only
Is the care and treatment restricted to the administration of
prescribed drugs (i.e. as prescribed by a general practitioner)
and first aid?
All please answer again
What facilities are available to the residents?
Maximum number of beds that can be maintained at the Home
Number of beds currently occupied
Details
of Employees
Please provide details of your employees (including working directors,
any persons supplied to or borrowed by you including self-employed
contractors) giving an estimate of the total remuneration to employees
and other persons without deduction of any kind (This figure will
be the estimated wages salaries and any other earnings including
overtime, value of board and lodgings, housing accommodation,
bonuses or other payments in kind or money. No deduction from
such remuneration should be made in respect of National Insurance,
Income Tax, Holidays with Pay or Contributory Pensions.
Nature of work undertaken
No. of employees/
Estimated total annual wages/salaries and other
earnings (£)
work undetaken at the home
work undertaken away from the home e.g. domiciliary
care, if nil state nil
Clerical/Admin staff
Nursing Staff/Care Assistants
Full Time Employees
Part-Time Employees including Bank/Agency Nurses/Care Assistants
Other Employees e.g Cleaners/Maintenance/
If you undertake any work away from the Home (such as domiciliary
care) in addition to the wages figure stated above, please advise
the turnover for these activities.
Nature of work
Turnover (£)
Home help and domestic work
Personal Care
Nursing
Other
if other please specify
Cover
Details
Contents
Sums to be insured
Residents' Effects (please check limit per person required)
Sum to be insured = limit required x maximum no. of residents.
All other Business Contents
(note: limit any one manuscript, printed book, journal, print,
painting, drawing, tapestry, sculpturenor other work of art £1,000
- Proprietor's household goods and personal effects should be
included later under household contents)
Consequential Loss
Indemnity period required? Note: The indemnity period should
be the length of time it would take to get your business back
to trading after a loss. You should take into account such factors
as site clearance, planning permission and rebuilding time.
Please check one only
Sum to be insured
Note: The sum to be insured should represent anticipated gross
revenue i.e. income, less the cost of purchases and laundry services.
If your selected indemnity period is longer than 12 months, increase
the sum insured in proportion remembering to allow for factors
such as increases in fees and expansion of the business.
Money
(a) Crossed cheques (but not pre-signed blank cheques), crossed
postal orders, crossed money orders, Premium Bonds, National Savings
Certificates, stamped NI cards, unexpired units in postal franking
machines, credit company sales vouchers and VAT purchase vouchers
LIMIT £250,000
(b) Other money
- outside business hours - at the Home or other specified location
in a locked safe subject to the suitability of the safe (standard
£1,500). Please give full details below
Make of Safe
Model
Age
Location and how fixed
(c) any other loss LIMIT £500
Optional
Covers
Buildings or Tenant's Improvements
Is this cover required?
click
here
if yes please give sum to be insured for:-
i) Buildings - Full rebuilding cost, including an allowance
for VAT if appropriate, architects' and surveyors' fees, legal
charges, debris removal and meeting Local Authority requirements
OR
ii) Tenant's Improvements - (if the buildings do not belong
to you)
Has there been a structural survey carried out?
if yes, were any adverse features revealed?
if yes, please give details
Household
Contents
Is this cover required?
click
here
if yes, please state the full replacement value of your private
possessions (including furniture, clothing, jewellery etc.) normally
kept at the Home, making a deduction for wear and tear on clothing
only
Does the replacement value of all your High Risk items exceed
one-third of the total sum insured for private possessions?
Note: High Risk items are articles of gold, silver or other precious
metal, pictures or other works of art, jewellery and furs.
Loss
of Registration
Is this cover required?
Sum to be insured
(maximum £100,000)
Is full terrorism cover required?
Do you require:
Fidelity Guarantee Insurance
Engineering Insurance
General
Questions
Are the external walls of the premises constructed solely of
brick, stone or concreteand are all roof coverings of slate, tiles
or concrete?
if no, please give details
Are the premises in a good state of repair and will they be so
maintained?
if no, please give details
Subsidence
Questions
a) Has any part of the property been affected by any movement
of any kind, for example subsidence, heave, landslip or settlement?
b) Is the neighbourhood in which the property is located susceptible
to subsidence, heave, landslip or settlement?
c) Has the property been underpinned or provided with other means
of structural support?
if yes to any of the subsidence questions above,
please give details
Storm
Questions
a) Is the property because of it's position , vulnerable to damage
by storm or flood?
b) Is the property on a site which has suffered from flooding
in the past ten years?
if yes to either of the storm questions, please give
details
Fire
Questions
a) Has the fire authority inspected the premises?
b) Have you completed all the fire authority requirements?
if no to either of the fire questions, please give
details
Will all machinery, lifting apparatus, boilers and steam vessels
be subject to regular inspections by qualified engineers?
if no, please give details
Registration
Questions
a) Please name the authority or authorities under which the Home
is registered
b) In whose name(s) is the home registered?
c) Please provide details of any outstanding requirements made
by the registration authority
What date has been given for the completion of these
requirements?
In respect of any registration, have there been any objections
to previous applications or any complaints or objections made
or do you know of any circumstances or incident which might affect
the future of any registration held by you whether at these or
any other premises owned or run by you?
if yes, please give details
About
the owners and/or person in charge
1) The Owner's name
Occupation
Qualifications
Experience (including any current or previous business
experience)
Person in charge's name
Occupation
Qualifications
Experience (including any current or previous business
experience)
Is the Home a registered charity?
Health
& Safety Questions
In accordance with the Health and Safety at Work etc. Act 1974,
the Management of Health and Safety at Work Regulations 1992 and
the Manual Handling Regulations 1992 are all Nursing, and Domiciliary
Care staff:
a) instructed and trained by suitably qualified personnel in
patient handling techniques?
b) specifically required to use the lifting/handling devices
provided where necessary?
c) required to undertake, where handling involving bodily force
is unavoidable, a detailed assessment of the task, the patient
(or load), the working environment and the operator(s) prior to
the lifting operation in order to minimise the risk if injury?
if no to any part of the Health and Safety questions,
please give details of the instructions given to your staff here
Do you have a written Health and safety policy as required by
the Health and Safety at Work etc. Act 1974 and has a copy been
given to all employees?
Do you maintain books of account and are they regularly audited
Are you now or have you previously been insured in respect of
any of the risks to which this proposal relates?
Have you or any owner, partner or director of the business:
a) in respect of the risks to be insured suffered any loss, damage,
injury or liabilty during the past five years at these or any
other premises whether insured or not?
b) had a company or underwriter decline to issue or renew a policy
or impose special terms?
c) ever been convicted of (or charged with but not yet tried
for) any offence other than a driving offence?
d) ever been declared bankrupt or the subject of bankruptcy proceedings
or made any arrangements with creditors either in a personal capacity
or in connection with any company, business or firm, with which
any of you have been involved?
e) been involved in any legal disputes during the past five years
in connection with any company, business or firm with which any
of you have been involved?
if yes to any of the questions a) to e) above please
give details including dates and details, amounts outstanding
and amounts paid (if applicable)
Insurance required from
Renewal Date of present insurance (if applicable)
Preferred Payment Method
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Credit Card
Debit Card
Cheque
Direct Debit
