Domiciliary Care Agency Application

Company Name & Contact Details:

Name of the Insured Firm(s), including any predecessor businesses and any trading names or styles used:

Contact First Name

e.g. John/Jane

Contact Surname

e.g. Smith

Your contact Email address:

Contact Phone Number (leave no spaces)

Can you confirm that you have no subsidiaries?

Please provide subsidiary company names

Does your business act solely as a supplier of staff for care-related services and not own, manage, or operate a care home or healthcare facility?

Are you currently registered with the Care Quality Commission (CQC), or in the process of applying for registration?

Date firm established

Please indicate which of the following care services your placements currently provide, or intend to provide in the case of a new business.

Please specify "Other" services undertaken

If you are human, leave this field blank.