Flowers Insurance Agency

877-282-3416

Does this risk an Experience Modification assigned by the State?	Yes No
Have there been any CAL-OSHA citations?	Yes No
Has there been any lapse in coverage for over 30 days in the past 12 months?	Yes No

General Eligibility
Does owner/manager have more than 3 years experience in this trade?	Yes No
Any Bankruptcy Filings (Chapter 7, 11)?	Yes No
Will the perspective employees have more than 1 year of average experience in this trade?	Yes No
Any work performed 15 feet or more, above or below the ground?	Yes No
Any work performed on or near water?	Yes No
Any work sublet without certificates of insurance?	Yes No
Any work performed outside Alabama?	Yes No
Are there any employee-leasing, or labor interchange exposures of any kind?	Yes No
Is there any USL&H or Jones Act exposure?	Yes No
Any volunteer or donated labor?	Yes No
Is any work performed on roofs or does any work require the use of pressurized combustible gases, or any demolition or blasting work?	Yes No
If contractor, does applicant sub-contract over 40% or gross receipts?	Yes No
Notice to applicants: This application must be completed in full as the quote will be based solely on the information provided. Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance containing any false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. By clicking "Submit", the applicant warrants that to their best knowledge all information given is true and accurate.