Flowers Insurance Agency

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Contact Information

Contact Name:

Name of Business

Address:

Address 2:

City, State & Zip:

Phone Number:

FAX

E-Mail Address:

Desired Limits: (Each Occurrence / General Aggregate) (other limits may be available upon request)

$300,000/$600,000

$500,000/$1,000,000

$1,000,000/$2,000,000

What percentage, if any, of gross receipts/revenues is derived from service and/or installation of products?

\What percentage, if any, of gross receipts/revenues is derived from the rental of any equipment?

Please indicate whether any of the following optional coverages are desired: (the limits provided will be the same as the limits chosen in number 1 above).

Employee Benefits Liability

YES NO

Liquor Liability

YES NO

If yes, please provide annual Liquor Receipts $

Hired and Non-owned Auto Liability

YES NO

Stop Gap Liability (ND, OH, WA, WV and WY only)

YES NO

Limited International General Liability Extension Endorsement

YES NO

Please indicate whether any of the following exclusions are desired.

a) General Liability Enhancement Endorsement (adds additional insureds and other broadening coverages).

YES NO

b) General Liability Extended Enhancement Endorsement (adds extended property damage and other broadening coverages).

YES NO