Proposer's Name		Contact Name
Address			Postcode
Telephone	A value is required.Invalid format.	Email	A value is required.Invalid format.
Address of Property if different
Business Description
No of Years In Business		Number of Employees	Renewal Date

Claims Experience	Date	Cause			Amount

Resident Categories		Number of Beds Registered For	Minimum 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?			No Yes
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

Buildings including all non-combustible outbuildings. Rebuild Cost					£
Stock of consumables					£
Contents (exc 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

			Number of Staff		Annual Wages
		Clerical Employees			£
		All other employees			£
		Manual Work Away			£
		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
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.