Florist Insurance Application

The below application should take about 10-15 minutes to complete. If you have any questions, you can contact a sales agent by calling 877-220-8719. Most questions are general in nature but you will also want to have the following information available:

BOP: Gross Sales, Property Information such as year built, limits needed, square footage and years of updates if over 20 years old.

Workers Compensation: Payroll, Number of Full & Part Time Employees & FEIN

Auto Information such as Drivers Information including Name, DL # and DOB, Vehcile VIN, Year Built, Make, Model Cost New, Deductible Options, etc.

General Questions

Insured Information

Business Name

DBA (Doing Business As) Name

Location Address

City

State

Zip Code

Mailing Address the same as physical address?

Yes

Mailing Address:

City:

State:

Zip Code

Contact Name (First, Last)

Phone Number

Number of locations

Year business established

Website Address

Entity Type

What is your BloomNet shop code?

How did you hear about us?

Please specify

Underwriting Information

For each line of coverage you are requesting a quote, was Insurance in place for the prior policy period (excluding new ventures)?

General Liability/Property

Yes

Not Quoting

Workers Compensation

Yes

Not Quoting

Auto

Yes

Not Quoting

If the business was established less than 3 years ago, how many years of management experience does the management team have in this industry?

Please provide details of experience

# of Members/Executive Officers

# of Employees

Annual Gross Sales

Has insured been non-renewed or cancelled during the past three years for any of the following reasons?

Do you have any subsidiaries or are you a subsidiary of another entity?

Yes

Please explain:

Is the business operation closed or temporarily suspended?

Yes

Are you a Franchisee?

Yes

Any bankruptcies, receiverships or related in the past five years?

Yes

During the last five years (ten in RI), has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other arson-related crime?

Yes

Have you been involved in any EPLI (Employment Related Practices) claims regardless of whether any payment or not, or do you have knowledge of any situation(s) that could produce an EPLI claim?

Yes

Please explain:

Do you sell liquor?

Yes

Do you have any additional operations such as event planning or furniture rental?

Yes

Have there been losses on the General Liability or Property in the last five years for the lines of business submitted (current term plus three most recent completed policy periods)?

Yes

GL/Property Losses Information:

Property Related Questions:

Property coverage could be the building you own or the property you use to conduct business such as equipment, furniture and inventory.

Do you want Property Coverage?

Yes

Is the building more than 20 years old?

Yes

Year of update for Roof

Year of update for Electrical

Year of update for HVAC

Year of update for Plumbing

Year Built

Roof Material

Construction Type

# of Stories

Total building square footage

Area occupied by insured

Area occupied by other tenants

Area unoccupied

Are there any other occupancies in the building? Examples include habitational, manufacturing, restaurants, retail, autobody work, woodworking, storage, vacant).

Yes

Please explain:

Is the building sprinklered?

Alarm Type

Business Personal Property Limit

Is your refrigerator equipment under a maintenance agreement?

Yes

Do you own your building?

Yes

Building Limit

Workers Compensation

Do you want Workers Compensation coverage?

Yes

Do you have any other business interests or activities other than your florist operations?

Yes

Please Explain:

Have you been non-renewed or cancelled during the past three years for any of the following reasons?

FEIN

Prior Carrier:

Employers Liability Limit Needed:

Do you know your Experience Modification?

Yes

Please enter:

Experience Modification Status:

Do you have any of the following types of employees? Labor Leasing or Contracted Employees, Employees from a PEO (Professional Employment Organization), Temporary Workers from Staffing or Employment Agency

Yes

Are any employees under 16 years of age?

Yes

Do you provide bicycle delivery?

Yes

Do employees perform work for any business not owned or operated by the insured?

Yes

Do any employees work from home?

Yes

Do you own, operate or lease aircraft that is used to transport employees in the conduct of your business?

Yes

Do 5 or more employees ever travel together?

Yes

Are MVRs for employees who regularly operate vehicles within their normal job duties reviewed periodically?

Yes

Do employees travel overnight?

Yes

Are you currently insured in an assigned risk pool or a non-voluntary market?

Yes

Total Employees at Location:

Maximum Employees at Location at One Time:

Class Description

Total Payroll:

# of FT Employees for this class

PT employees for this class

Do you wish to include any individuals/partners/officers?

Yes

How many?

Have there been any OSHA violations in the past 36 months?

Yes

Are any machines used in the scope of Insured`s operation?

Yes

Do employed drivers operate trucks with a gross vehicle weight (GVW) or gross combination weight (GCW) of greater than 26,000 pounds?

Yes

Does the insured verify that Commercial Drivers Licenses (CDL) are in place for these drivers?

Yes

Are MVRs for employees who regularly operate vehicles within their normal job duties reviewed periodically?

Yes

Have you had any Workers Compensation claims in the prior 5 completed policy years?

Yes

Workers Compensation Claim Information:

Auto

Do you want Auto coverage?

Yes

Do all drivers have a valid U.S. driver's license?

Yes

Does the insured have any drivers that require an individual financial responsibility filing?

Yes

Do you prescreen MVRs for employees and volunteers (when applicable) who drive vehicles upon hire and intermittently thereafter?

Yes

Prior Carrier:

What percentage of employee's operate their personal vehicles for the customer's business?

For All Drivers we need the following Driver Information

Driver Collection

FOR ALL VEHICLES WE NEED THE FOLLOWING VEHICLE INFORMATION

(For all vehicles owned or leased on a long term basis)

Auto Liability Limits

(CSL - Combined Single Limit)

Do you deliver?

Yes

Do you utilize a vehicle tracking system such as BloomNet Technologies FREE Route4Me App?

Yes

Which of the following methods of delivery are used by the insured? (select all that apply)

Delivery Radius:

Are there any vehicles owned by the business that will not be insured on this policy?

Yes

Please explain:

Are all vehicles registered under the business name or individual if sole proprietor?

Yes

Are there any loss payees or additional insureds needed?

Yes

Do you use the BloomNet Business Management System, Route4Me for your deliveries (or a similar tracking program)?

Yes

Have you had any Auto claims in the prior 5 completed policy years?

Yes

Auto Claim Information:

Terms and Conditions

I agree to the above Terms and Conditions

Signature of Applicant:

Date