Name*

Business Name*

Address

Post Code*

Telephone Number*

Facsimile Number

Email*

Renewal Date

Current Insurer

Resident Category

(e.g. Elderly/Dementia/Learning Difficulties/Mental Health Difficulties/Children)

Indemnity period - select - 12 months 18 months 24 months 36 months

Estimated annual turnover  £

Assets to be covered, if applicable:

Building £

Contents £

Residents' effects £

Location/s (if different to above)

Claims experience for the last three years

Please detail any incidents which may give rise to a claim, detailing incident date, summary of circumstances and insurers cost or reserve:

Optional Fields

‘All Risks’ items – these are items which you may regularly take away with you or your staff for the purposes of your job which need to be covered while away from your premises, e.g. mobile hoists.

Item 1

Value

Comments, if any

Item 2

Value

Comments, if any

CHIS or our insurance underwriting partners may require additional information from you.