Domiciliary care agency insurance quote form

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Part 2: Business Details
What date was your business established?*
Estimated turnover for the coming year (£)*
Please indicate the percentage split of turnover:
Elderly (%)*
Mental Health (%)*
Learning Difficulty (%)*
Drug/Alcohol Rehabilitation (%)*
Physical Disability (%)*
Service Users Under 18 Years of Age (%)*
Challenging Behaviours (%)*
Other (please specify)
Percentage of turnover relating to providing staff to third party organisations (%)*
Percentage of wageroll relating to qualified nursing (%)*
If this is a new company - what experience and qualifications in the care / health and social work industry are held by yourself or other managers?*
Please detail any additional activities you provide*
Activities other than: Elderly, Mental Health, Learning Difficulty, Drug/Alcohol Rehabilitation, Physical Disability, Service Users Under 18 Years of Age

Part 3 - Cover Details
Are you registered with CQC?*
Is nursing care provided?*
Do you carry out DBS checks?*
Do you carry out ID checks and reference checks on all staff?*
Do you require buildings cover/personal accident?*
Do you loan staff to third party care homes/hospitals?*
Do you provide care to service users that display challenging behaviour?*
Do you provide any care or activities over and above the following agreed activities?*
Personal Care – Bathing/Dressing – Administering of Prescribed/Non-Prescribed Medicines, Night Care, Carers Respite Service, Cleaning/Cooking/Household Tasks, Shopping & Laundry, Handyman & Gardening Services, Escorting In Public/Chaperoning, Accompanying Service Users on Holiday.
Will you accompany your clients on holiday?*
Do you have any protection of vulnerable adults policy in place?*
Has any Director or Partner of this company been involved in any previous company which as gone into bankruptcy / insolvency or liquidation?*
Has any Director or Partner of this company any criminal convictions or pending criminal convictions?*
Has any insurer declined your proposal / cancelled or refused to renew your policy / required an increased premium or imposed special terms?*
Who is your current insurance provider?*
Claims history*
Please supply details of any claims you have made
What date would you like your policy to begin?*

Part 1: Your Details