| Nursing
& Care Home Insurance - Quotation Request
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Proposer's name
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E-mail address
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Trading name
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Address to be insured
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Postcode
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Contact Name
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Correspondence address (if different from above)
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Postcode
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Telephone No |
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Fax No (optional)
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Are you an existing Rowett Insurance client?
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Yes
No
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About the business
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Registration under the Registered Home Act 1984. Please
check which of the following categories apply
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Small Homes (Amendment Act) 1991
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Registered: Solely under part 1
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Dual-Registered
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Registered: Solely under part 2
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If the home is subject to any other type
of registration please specify
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This question is for For Homes in Scotland only
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Is the care and treatment restricted to the administration
of prescribed drugs (i.e. as prescribed by a general practitioner)
and first aid?
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Yes
No
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All please answer again
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What facilities are available to the residents?
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Maximum number of beds that can be maintained at the Home
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Number of beds currently occupied
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Details of Employees
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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.
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Nature of work undertaken
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No. of employees/
other persons
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Estimated total annual
wages/salaries and other earnings (£)
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work undetaken at the home
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work undertaken away from the home e.g. domiciliary
care, if nil state nil
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Clerical/Admin staff
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Nursing Staff/Care Assistants
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Full Time Employees
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Part-Time Employees including Bank/Agency Nurses/Care Assistants
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Other Employees e.g Cleaners/Maintenance/
Gardeners
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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.
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Nature of work
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Turnover (£)
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Home help and domestic work
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Personal Care
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Nursing
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Other
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if other please specify
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Cover Details
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Contents
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Sums to be insured
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Residents' Effects
(please check limit per person required)
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£500
£1,000
£2,500
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Sum to be insured = limit required x maximum no. of residents
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All other Business Contents
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(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)
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Consequential Loss
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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.
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Please check one only
12 months
18 months
24 months
36 months
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Sum to be insured
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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.
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Money
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(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
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LIMIT £250,000
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(b) Other money
- in transit, bank night safe or in the home during business
hours (standard £3,000)
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- 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
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Make of Safe
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Model
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Age
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Location and how fixed
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(c) any other loss LIMIT £500
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Optional Covers
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Buildings or Tenant's Improvements
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Is this cover required?
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Yes
No (if no, click here)
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if yes please give sum to be insured for:-
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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
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OR
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ii) Tenant's Improvements - (if the buildings do
not belong to you)
- Landlord's fixtures and fittings and internal decorations
for which you are responsible
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Has there been a structural survey carried out?
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Yes
No
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if yes, were any adverse features revealed?
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Yes
No
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if yes, please give details
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Household
Contents
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Is this cover required?
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Yes
No (if no, click here)
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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
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(minimum £5,000)
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Does the replacement value of all your High Risk items
exceed one-third of the total sum insured for private possessions?
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Yes
No
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Note: High Risk items are articles of gold, silver or other
precious metal, pictures or other works of art, jewellery
and furs.
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Loss of Registration
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Is this cover required?
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Yes
No
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Sum to be insured
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(maximum £100,000)
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Is full terrorism cover required?
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Yes
No
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Do you require:
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Fidelity Guarantee Insurance
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Yes
No
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Engineering Insurance
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Yes
No
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General Questions
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Are the external walls of the premises constructed solely
of brick, stone or concreteand are all roof coverings of
slate, tiles or concrete?
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Yes
No
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if no, please give details
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Are the premises in a good state of repair and will they
be so maintained?
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Yes
No
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if no, please give details
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Subsidence Questions
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a) Has any part of the property been affected by any movement
of any kind, for example subsidence, heave, landslip or
settlement?
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Yes
No
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b) Is the neighbourhood in which the property is located
susceptible to subsidence, heave, landslip or settlement?
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Yes
No
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c) Has the property been underpinned or provided with other
means of structural support?
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Yes
No
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if yes to any of the subsidence questions above,
please give details
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Storm Questions
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a) Is the property because of it's position, vulnerable
to damage by storm or flood?
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Yes
No
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b) Is the property on a site which has suffered from flooding
in the past ten years?
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Yes
No
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if yes to either of the storm questions, please give
details
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Fire Questions
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a) Has the fire authority inspected the premises?
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Yes
No
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b) Have you completed all the fire authority requirements?
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Yes
No
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if no to either of the fire questions, please give details
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Will all machinery, lifting apparatus, boilers and steam
vessels be subject to regular inspections by qualified engineers?
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Yes
No
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if no, please give details
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Registration Questions
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a) Please name the authority or authorities under which
the Home is registered
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b) In whose name(s) is the home registered?
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c) Please provide details of any outstanding requirements
made by the registration authority
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What date has been given for the completion
of these requirements?
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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?
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if yes, please give details, if no please
state 'no'
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About the owners and/or person
in charge
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1) The Owner's name
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Occupation
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Qualifications
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Experience (including any current or previous
business experience)
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Person in charge's name
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Occupation
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Qualifications
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Experience (including any current or previous
business experience)
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Is the Home a registered charity?
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Yes
No
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Health & Safety Questions
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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:
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a) instructed and trained by suitably qualified personnel
in patient handling techniques?
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Yes
No
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b) specifically required to use the lifting/handling devices
provided where necessary?
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Yes
No
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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?
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Yes
No
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if you have answered no to any of the Health and Safety
questions, please give details of the instructions given
to your staff here
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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?
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Yes
No
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Do you maintain books of account and are they regularly
audited
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Yes
No
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Are you now or have you previously been insured in respect
of any of the risks to which this proposal relates?
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Yes
No
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Have you or any owner, partner
or director of the business:
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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?
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Yes
No
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b) had a company or underwriter decline to issue or renew
a policy or impose special terms?
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Yes
No
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c) ever been convicted of (or charged with but not yet
tried for) any offence other than a driving offence?
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Yes
No
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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?
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Yes
No
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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?
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Yes
No
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if you have answered yes to any of the questions a) to
e) above please give details including dates and details,
amounts outstanding and amounts paid (if applicable)
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Insurance required from
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Renewal Date of present insurance (if applicable)
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Preferred Payment Method
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Nursing
& Care Home Insurance
