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Registration Please fill in the form below. You must fill in all the boxes except where otherwise indicated. Once your payment is received, the Administrator will activate your account and confirm this by e-mail. You can then begin using Care Home Insurance for the next 12 months. Please read our Terms and Conditions for use.
First name
Surname
Email Address
Number of Employees
Company
Address

City
Counties
Postcode
Type of Company
Second Company
Third Company
Telephone Number
Fax Number	[optional]
Web Address	http:// [optional]
Company Description	[optional]
Agree to Terms & Conditions	[you must tick this box to proceed]

REMEMBER YOUR PASSWORD! You will need this password each time you log in to Care Home Insurance

Username	[choose a username]
Password	[choose a password]
Confirm Password

* unless stated all fields are required to be completed.

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