ࡱ>  @ 2bjbj$$ 2FF(3ffffGGG8G4"HLczKzK4KKKMMMc c c c c c c$?dRfb.cPEM@MPP.cffKKCc8U8U8UPfRKKc8UPc8U8U"8UKnK KG6QB8UtU Yc0c8UfxRbf8Ufffff8U<MON8UNtSOaMMM.c.c$@ET^E  1) Full Name of Proposer (please show any trading name and names of any subsidiary companies to be insured)2) Postal AddressPostcodeTel. No3) Date established4) Period of InsuranceFrom / / To / /5) Full business description 6) Do you own or operate any care home or similar establishment?Yes/No 7) Cover and Limits requiredEmployers LiabilityYes/No10m standard Limit of IndemnityPublic LiabilityYes/NoIf Yes - indicate Limit of Indemnity required?1m 2m 5m or other MalpracticeYes/NoIf Yes - indicate Limit of Indemnity required?1m 2m 5m or other  8) Please provide details of the qualifications and experience of all Principals/Partners/Directors NameDetails of qualifications and experience 9) Please provide a split of your business activities between -Description of activity% of Total Incomea) Domiciliary Care (i.e. provision of care in clients own homes)%b) Care provided in Nursing Homes/Residential Homes/Care Homes/Hospitals%c) Other activities please specify these below -%%%% 10) Please provide a percentage split in the care givenPhysically Disabled%Mentally Disordered%Children%Learning Difficulties%Drug/Alcohol Rehabilitation%* Other%Convalescence%Elderly%* If you have shown a figure against Other would you please give a description of each type of care and percentage below%%%%%% 11) Do you have a written Health and Safety Policy?Yes/No12) In respect of all carers do you a) undertake a police check through the Criminal Records Bureau (CRB)?Yes/No b) check their qualifications?Yes/No c) look into any gaps in their employment history?Yes/No d) take up references?Yes/No13) If references are taken up please confirm how many and from whom14) Do you keep a record of regular risk assessments?Yes/No15) Do you enter into any contracts or agreements with customers which may effect your liability under  statute or common law? (If Yes please supply copies of contracts or agreements)Yes/No16) Have you ever been prosecuted under the Health and Safety at Work Act, the Consumer Protection Act or any other Statutory Regulations?Yes/No17) Have you or any of your business Partners or Directors ever been convicted of or charged (but not yet tried) with a criminal offence other than motoring convictions?Yes/NoIf you have answered Yes to either of the last two questions please give details below including dates and outcome. 18) Does your work involve any manual handling or lifting of clients?Yes/No  If Yes - Please state approximately what percentage of clients require manual handling or lifting% Do you ensure that staff involved with manual handling or lifting receive appropriate training and that training records are kept and maintained?Yes/No PLEASE PROVIDE A COPY OF YOUR MANUAL HANDLING AND LIFTING PROCEDURE 19) Have you or any Partners or Directors been involved in any other business in the last 5 years?Yes/No If Yes please give details 20) Name of existing/previous insurer 21) Has any insurer declined your proposal, cancelled or refused to renew your policy, required an increased premium or imposed special terms?Yes/No If Yes please give details 22) Give details of any LIABILITY claims or incidents which may result in a claim that have occurred over the last 5 years. Include dates, a description of the circumstances and the costs involved. If none then please write None below. 23) Please provide the following information. Category of persons employed - NB You must also include Principals, Partners, Directors and any Self Employed persons.Estimated Number of PersonsEstimated Annual Wages/Salaries or Paymentsa) Clerical/Managerial/Administrative persons who do not work manuallyb) Professionally qualified persons (e.g. Nurses)c) Auxiliariesd) Carers/Home Helpse) Others please specify these below i) ii) iii)f) Bona Fide Sub Contractors 24) What was your total Turnover during the past 12 months?25) What is your estimated Turnover for the next 12 months? Please complete the following questions only if you require Malpractice cover otherwise proceed to the DECLARATION on the final page. MALPRACTICE - SUPPLEMENTARY QUESTIONS PLEASE NOTE THAT THIS POLICY IS DESIGNED TO COVER CLAIMS MADE AGAINST THE INSURED. IF COVER IS ALSO REQUIRED FOR CLAIMS MADE AGAINST REGISTERED MEDICAL/ DENTAL PRACTITIONERS FOR WORK PERFORMED FOR THE INSURED, PLEASE SUPPLY A LIST OF ALL SUCH PRACTITIONERS FOR WHOM COVERAGE IS REQUIRED STATING THE NAME, D.O.B., QUALIFICATIONS AND PRACTICE OF EACH PRACTITIONER. IN ADDITION TO THIS PLEASE CONFIRM WHETHER OR NOT THE PRACTITIONERS ARE EMPLOYED BY THE INSURED OR SELF-EMPLOYED. 26) Do you carry out the administration of any medication?Yes/NoIf Yes, do you have a written policy dealing with the procedure for administration of medication?Yes/No 27) Are all qualified nurses required to maintain their own cover through the RCN or similar?Yes/No28) Do you ensure and record that at all times all Registered Medical and Dental Practitioners are members of a Medical / Dental Defence Organisation, recognised by your National Medical / Dental Association, or are otherwise fully Insured for their own Malpractice?Yes/NoIf the Answer is NO please refer to note above. 29) Are you duly licensed and registered in accordance with the Care Quality Commission (CQC)  and do you carry an up to date Certificate of Registration?Yes/No If Yes, please enclose the following additional documentation a) Copy of your Statement of Purpose (as required by your application) b) Copy of the most recent CQC reportIf No or if you are unable to provide any of the above, please provide details including  anticipated date of registration and/or first inspection  30) Please give details of the minimum qualifications of carers (e.g. First Aid, carers course, nursing experience, etc.)  31) Please give details of how patients records are kept 32) Name of existing/previous Malpractice insurer 33) Has any insurer declined your proposal, cancelled or refused to renew your policy, required an  increased premium or imposed special terms?Yes/No 34) Give details below of any claims or incidents which may result in a claim that have occurred over the last 5 years to  include dates, a description of the circumstances, the costs involved and whether your insurers were notified. If none then please write None below. DECLARATION I/We declare that to the best of my/our knowledge and belief the above statements and particulars, whether written by me/us or my/our behalf are true and complete and that I/we have not mis-stated or suppressed any material facts. I/we agree that this proposal and declaration, together with any information supplied by me/us shall be the basis of the contract between myself/ourselves and the Underwriters standard form of policy for this class of insurance. Signed Date IMPORTANT Material Facts are those facts which are likely to influence the acceptance or assessment of this Proposal and it is essential that you disclose them. If you are in any doubt whether a fact is material then for your own protection you should disclose it since failure to do so could invalidate your insurance. Please use the following space if you wish to provide any further information  DATA PROTECTION The defined terms used in this section shall have the meaning given to those terms in the Data Protection Act 1998 (as may be amended from time to time). In the course of providing insurance services to the proposed insured/insured, the insurer may have access to Personal Data. The proposed insured/insured warrants that it shall have obtained all necessary authorisations and approvals from Data Subjects prior to disclosing any Personal Data to the insurer (whether such disclosure is made directly by the proposed insured/insured to the insurer or indirectly by the proposed insured/insured to any agent acting on behalf of the proposed insured/insured or the insurer). The insurer shall be the Data Controller of any Personal Data provided to it. The insurer undertakes that it shall only use any Personal Data provided to it for the purposes of performing its services in connection with its contract of insurance with the proposed insured/insured. This will include the processes of underwriting, administration and claims assessment as well as any necessary services ancillary thereto. The insurer will hold all Personal Data provided to it securely and shall limit access to such Personal Data to those who have a need to see it. The proposed insured/insured hereby consents to the insurer sharing any Personal Data provided to it with its group companies, agents, reinsurers, claims handlers, loss adjusters, medical professionals and other professional advisors, healthcare management companies and any other necessary service providers with whom the insurer contracts in connection with the proposed contract/contract of insurance between the proposed insured/insured and the insurer The insured acknowledges that the insurer may be required as a matter of law or regulation to disclose Personal Data provided to it to a Court of law or regulatory body such as the Financial Services Authority or any other public body or authority of competent jurisdiction and the proposed insured/insured hereby consents to any such disclosure. The proposed insured/insured acknowledges that the insurance industry maintains certain registers for the purposes of fraud prevention and hereby consents to the insurer sharing Personal Data provided to it with fraud prevention agencies and other insurance companies for the purposes of fraud prevention and to validate your claims history.     PAGE  PAGE 1 PAGE 1 LIABILITY and MALPRACTICE PROPOSAL FORM for DOMICILIARY CARE PROVIDERS INSURANCE SCHEME (DCPIS) An exclusive scheme arranged through the Company Market and Lloyds Underwriters by H.J. 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