Camberford Law PLC

Malpractice Proposal Form
Nursing and Residential Homes and Hospices
Section 1

1. Full name and address of Home/Hospice

2. Name(s) of Owner(s) or Partners and details of experience / qualifications

Name	Experience/Qualifications

3. How long have you operated under the present management?

4. Please state your gross annual income for the last financial year

5. Please state your estimated gross annual income for the current financial year (and the date of your year end)

6. Please state your estimated gross annual income for the next financial year

Guidance Notes

Please answer all questions fully and carefully. There is a duty to disclose all material facts. Material facts are those that affect the judgment of a prudent Underwriter.

The proposal form and the information you provide forms the basis of the insurance policy you are purchasing and therefore is extremely important. Full disclosure should eradicate many issues at the time of a claim being made on the policy.

Full Name of Proposer
If a Limited Company please insert this name in the full name of the Proposer.
If a sole trader – please list your name in the full name of the Proposer and any Trading Name below this.
If a partnership, list all partners’ names in Full Name of Proposer and any Trading Name in the next box.

Business Description
Please make sure that you list every activity you undertake to ensure we cover your activities correctly and prevent any issues at the time of making a claim ie. Any door supervision work, chauffeuring etc. Question 1
Please include company/partnership name if that is how constituted.

Questions 4/5/6
Please include all income/fees/commission you receive and are likely to receive from any source in relation to questions 4, 5 and 6.

T: 020 8315 5000

F: 020 8460 2118

E: mail@camberfordlaw.com