Care Services Combined

Proposal Form

Section 1: General Information

This section must be completed.

Your Principal Company

Name
Main Office Address
Postcode
Date of Establishment
Website
Contact Name
Email
Phone

Employer Reference Number (ERN)

Following the new regulatory requirements introduced in 2012, we need information from you for the Employer’s Liability (EL) database to ensure claimants can trace insurers in event of an Employers’ Liability claim.

Please provide us with your ERN below

Employer Reference Number

UK Subsidiary Companies

Please state all subsidiary companies which are registered within the UK that will require to be covered under this policy:

Company Name	Employer Reference Number (ERN)

Business Activities

Are you involved in the supply of:
Medical/Nursing/Domiciliary Care Staff to business or charities (Care Homes)
Medical/Nursing/Domiciliary Care Services direct to private individuals in their homes
If you are involved in any other services which fall outside of the above, please detail below;
Has your business been / is your business required or do you propose to register with a regulatory body such as the Care Quality Commission, the Care and Social Services Inspectorate Wales (CSSIW) or any other body which may inspect or audit your services?
Please confirm the exact date of the last inspection and attach that report.
Other than administering or passing non-prescription or prescription drugs, do the staff participate in any other form of medical or paramedical services such as PEG feeding tubes, please provide information below;
Do you have a separate Medical Malpractice insurance policy in place to cover this element of your services?
Do your staff have access to money belonging to service users?
How often do you independently audit or reconcile accounts or money of the service users which are accessible by the staff under your employment and providing the day-to-day care to those parties?
Please confirm that your staff turnover is less than 35% per annum
Please confirm that your current vacancy rate is below 5%
Please confirm your staff to service user ratio history (5 staff to 30 Service Users is a 5:30 ratio)
Staff/Service User Ratio in past year?	Staff/Service User Ratio in this year?
Has your office manager has been in place for three years or more
Do you regularly review and update your infection protection control risk assessments and procedures in line with Government guidelines and record when any changes have been made?
Can you formally demonstrate that you communicate these changes to your employees and or volunteers?

4. Safeguarding

Definitions

Employee includes employees (full and part time), directors, partners, contractors, volunteers, and agency staff.

Vulnerable Person is a minor (someone under the age of 18) or someone who, for physical or mental reasons, is unable to look after themselves or their finances.

Procedures

Do you have a Safeguarding Policy that has been made available to all Employees and includes a statement of intent on safeguarding Vulnerable Persons?
Does this include an anti-bullying policy?
Does this mention a designated person who is responsible for all Vulnerable Persons protection issues and is this role clearly defined?
Do you have a documented method to ensure the Safeguarding Policy is kept up to date?
Do you have a written code of conduct for all Employees that has been made available to all Employees and outlines appropriate behaviour towards Vulnerable Persons?
Do you have policies and procedures on how you manage the challenging behaviour of Vulnerable Persons that have been made available to all Employees?
Do you have written guidelines, that have been made available to all Employees, on:
intimate care of and appropriate conduct towards Vulnerable Persons?
supervision of Vulnerable Persons’ whilst away from the premises?
If you provide overnight accommodation, do you have suitable policies, procedures, guidance, training, and supervision in place in relation to the provision of this that have been made available to Employees?
If you have answered “No” to any of the questions under this section, please provide details below:

Recruitment

Do advertisements for job vacancies make reference to your Safeguarding Policy and screening?
Are written references required and do you carry out checks to ensure they are accurate and relevant?
Do successful candidates sign a personal declaration of criminal convictions?
Do you:
undertake Disclosure and Barring Service checks (“DBS”) including, where appropriate, enhanced DBS checks with barred list or similar statutory disclosure checks for all new Employees before their start date?
complete DBS rechecks for all Employees on a regular basis*?
*Some policies will make reference to how frequent DBS rechecks should be. Please refer to your policy documentation for more information
If you have answered “No” to any of the questions under this section, please provide details below:

Training

Is there induction training for all new Employees prior to their start date that includes Safeguarding Policy principles and procedures relevant to your sector?
Is this refreshed on a regular basis to ensure it is up to date?
Do your Employees receive ongoing supervision, support and appraisal?
Is all training recorded and signed for by all Employees?
If you have answered “No” to any of the questions under this section, please provide details below:

Reporting Protocols

Do you have a process for reporting and reacting to witnessed, suspected or alleged abuse of Vulnerable Persons and/or violation of the Safeguarding Policy that has been made available to all Employees?
Do you have a whistleblower policy including a formal whistleblowing investigation procedure that has been made available to all Employees?
Are there arrangements in place for the protection of both the whistleblower and Employee(s) who have had allegations raised against them during the investigation process?
If you have answered “No” to any of the questions under this section, please provide details below:

Record Keeping

Do you securely retain for a minimum of thirty (30) years the following documents:
employment & engagement applications, references, identity verification, records of DBS or similar statutory disclosure checks
your Safeguarding Policy including any revisions
records of Safeguarding Policy training
your accident and incident registers
records of any alleged, actual or threatened abuse and action taken including any notifications to relevant authorities
referrals, assessments, treatment and care plans for any Vulnerable Person in your care
If you have answered “No” to any of the questions under this section, please provide details below:

General

Have you had any enforcement action in relation to Vulnerable Persons in the last five (5) years and, if so, what was the outcome?
Is your organisation audited/accredited by a third-party approving body that includes your Safeguarding Policy?
If you have answered “Yes” to (A) please provide details below:

Please note that we do not require to see proof or copies of procedures or plans. It is sufficient to know they exist and will be available in the event of a claim.

Estimated Annual Wages

Wages means salaries and other earnings paid, National Insurance, Pensions contributions and Tax to your own employees, engaged for the running of your company, including payments to directors.

Annual total wageroll paid to your office-based employees carrying out clerical duties;	£
Annual total wageroll paid to employees carrying out domiciliary care work;	£
Annual total wageroll paid to temporary workers that are carrying out domiciliary care work;	£

Overseas Work

Is all business conducted from within the UK?
Are you involved in any activities for the supply of services overseas?

Your Current Policy

Current Insurer
Renewal Date
Premium Paid	£

Cover Required

Combined Liabilities – Required?

Limits of Liability

Employers Liability
Public and Products Liability
Professional Indemnity – Required?

Limits of Liability

Please select the limit of indemnity you require

Gross Turnover

Please confirm your gross turnover for both your last financial year and your forthcoming year.

Last Financial Year	Forthcoming Financial Year
Total Turnover	£	£

Retroactive Date

Please note that your retroactive date can be found under the professional indemnity section on your current policy schedule.

Please state your current retroactive date

Material Damages & Business Interruption – Required?

Your Additional Office Premise(s)

If you have additional office locations that need to be included, please list them below

1	Main office address (already specified at the beginning of this form)
2
3
4
5

Property Sums Insured Required

Premises
1	2	3	4	5
Computers	£	£	£	£	£
All other contents	£	£	£	£	£
Tenants Improvements	£	£	£	£	£
£	£	£	£	£

Fire and Security

Please advise if you have a security alarm
Do you have a Fire Alarm?
If yes, is this alarm subject to a maintenance contract with a Loss Prevention Council, NSI or SSAIB approved company?

Specified Business Equipment

Please state any property to be insured whilst away from the premises (such as laptops or mobile phones), the sum insured for the total of the items, and the region.

Description of Item(s)	Sums Insured	UK, Europe or Worldwide
Laptops	£
Mobile Phones	£
Other – Description:	£

Business Interruption

Please specify your preferred your required sums insured.

Insured Items	Sums Insured
Option A	Loss of Revenue including Additional Expenditure	£
Option B	Loss of Revenue including Additional Expenditure (but excluding payments made to temporary workers supplied)	£
What period do you require Loss of Revenue to be insured over?

Or

Option C	Additional Office Expenditure Only	£
What period do you require Additional Expenditure to be insured over?

Outstanding Debit Balances

Please estimate the maximum amount of debit balances that could be outstanding at any one time.

Sum Insured	£

Buildings

Premises
1	2	3	4	5
Buildings Sum Insured	£	£	£	£	£
Rent Receivable	£	£	£	£	£
Are all buildings
Built to standard construction?
Are there any signs of damage that could be due to subsidence, landslip or heave?

Legal Expenses – Required?

Legal Expenses

Please select the limit of indemnity you require

Gross Turnover

Please confirm your gross turnover for both your last financial year and your forthcoming year.

Last Financial Year	Forthcoming Financial Year
Total Turnover	£	£

Group Personal Accident – Required?

Personal Accident

The standard policy will provide a fixed benefit of up to £10,000 for death, loss of limb(s) and loss of sight.

Do you require cover for your own permanent employees?

Directors and Officers Insurance – Required?

Limits of Liability

Limit Required
Directors and Officers Liability

Extensions

Required?	Limit Required?
Employment Practice Liability
If required, please provide the number of own employees
Entitys

Claims Declaration

After full enquiry, is any director, partner, principal, or employee aware of any claim over the last 3 years under any insurance policies identical or similar to those insurances for which you are now requesting quotations (whether or not such insurances are currently in force)?
After full enquiry, is any director, partner, principal, or employee aware of any potential claim, incident or circumstance that would or may have given rise to a claim under any of the proposed insurances for which you are now requesting quotations?
After full enquiry, is any director, partner, principal, or employee aware of further facts that may affect the proposed insurances for which you are now requesting quotations?

If yes, please give full details, including any actual or estimated settlement cost:

Date of Loss	Section of cover claimed under	Amount paid	Or Outstanding Estimate

General Declaration

Declaration

In proceeding with this proposal, and with any subsequent insurance contract, I/we declare that any statements made by me/us whether on my/our own or on others’ behalf are accurate and complete to the best of my/our knowledge and belief, and I/we acknowledge and agree that they will form part of the contract with insurers. I/We agree to accept a policy in the insurer’s normal form for this class of business. Before proceeding to the next stage in the Proposal, please check your answers carefully. Proceeding with this proposal does not bind either you or the insurers to complete the insurance until such time as you specifically agree to purchase the insurance quoted and the insurers specifically agree to provide the insurance. The proposal and any supporting information supplied will be the basis of any resulting contract or insurance and will be incorporated into the contract. All questions must be answered fully and truthfully to the best of your knowledge and belief. If you consider that any questions require knowledge which you do not have or are not sure of, you should contact us to outline your concerns. All material facts must be disclosed, including any which might arise or change between the date of this Proposal and the start date of any contract of insurance based upon this Proposal. Failure to do so may render any such contract null and void. A material fact is one likely to influence acceptance or assessment of this Proposal. If you are in any doubt as to what constitutes a material fact you should disclose it. If you are in any way unsure, you should contact us to outline your concerns. We recommend that you keep a record, including copies, of this Proposal for and all information supplied to us for the purpose of entering into this contract. Copies of your responses will in any event be attached to your quotation for convenience.

Acceptance of Declaration

I confirm that I have read and understood the above declaration.

Name:

Position:

Signature:	_____________________________

Date:	24 May 2022

Additional Information

Please provide any additional information which you believe is material to the insurances that you have requested cover for.