Fields marked with a * are mandatory
Title*:
Full name* :
Email address* :
Contact no* :
Mobile no (if different):

Postal address:

Postcode:
Proposer (full trading name):
Risk address (if different):
Fax no:
Website address:

Please list any additional activities you may 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 and laundry
  • Handyman and gardening sevices
If qualified nursing care is to be provided, please indicate
the percentage of turnover:
What is your anticipate turnover for the coming year?
Do you wish to include personal accident benefits?
(please note additional premium payable)

Are you registered with the Commission of Social Care Inspection?
If no state why:


Have the National Care Standards Commission undertaken an audit in the last year?
If yes, please provide the date of inspection (DD/MM/YY)


Were any requirements imposed as a result of the audit?

If yes to the above question, have they been implemented?
If no, please detail why:


Do you carry out risk assessments prior to commencing
provision of care to a new client/service user?

Are the premises built of brick, stone or concrete and roofed
with slate, tile, concrete, metal, asbestos or concrete
sheeting?
If no, please provide details:

Have you suffered any claim in the last 5 years?
If yes, provide full details:


Contact method:
Contact time:
How did you hear about us? *
Please tick the box if you prefer not to receive marketing communications from us by post or telephone. 
Please tick the box if you prefer not to receive marketing communications from us by email, text messaging or other electronic means.