Quotation Request Form

To request an insurance quotation please complete our short online quotation request form below

Proposers Name
Address
Tel:
Email:
Date business established
Renewal Date
Detail any additional activities you 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)
Do you require the additional personal accident extension	Yes    No
Are the office premises built of standard construction	Yes    No
Are you Registered with the Commission of Social Care Inspection	Yes    No
Anticipated Turnover for coming year
Are there any specific services offered for people with learning difficulties or special childcare services provided ?	Yes    No
If so please provide full details:
If qualified Nursing care is provided please indicate the percentage of turnover	%
If childcare is provided please indicate percentage of turnover	%
Please provide an approximate percentage split of the environments where care will be provided into:
Individuals Own Homes	%
Residential Homes	%
Nursing Homes	%
Hospitals	%
Are there any specific trading conditions when providing staff into the above environments which pass the onus of liability on	Yes    No
Name of existing Insurer
Has any Insurer declined your proposal, cancelled or refused to renew your policy, required an increased premium or imposed special terms	Yes    No
Have you suffered any claims in the last 5 years	Yes    No
If Yes please give details Claims History (Please supply full details)

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