Accountants Professional Liability insurance

Application for Accountants Professional Liability Insurance

(claims-made and reported basis) Please answer each question completely. If there is no answer, write "none" or "not applicable" in the space provided.

Part I : Firm Profile

1 Legal name(s) :

Contact name* :

2 Address of the firm's principal office :

City : County : Zip :

Telephone* : Fax :

E-Mail*:

Date established :

Attach a list of any branch offices and indicate if there is a partner at each location.

3 Professional associations/affiliations :

State Society Other:

AICPA : Division/Committee memberships :

4 Are there any predecessor firms or acquired firms? Yes No

If yes, complete Appendix I, Predecessor and Acquired Firm History.
Only those firms listed will be considered for coverage.

5 Indicate number of personnel:

Partners, principals or shareholders

Employed CPAs

Other accountants

Non-accounting professionals (describe):

Other staff

Total

6 Is applicant, or any partner, shareholder, principal or employee licensed as a lawyer, insurance agent or broker, real estate agent or broker, securities dealer or registered investment advisor?
Yes No

If yes, please provide the following information :

Name

Type of License

Professional Liability Insurer

Policy Limits

Part II : Practice Profile

7 Last Three Fiscal Years

Total Gross Income (Net Any Allowances) From The Applicant's Professional Accounting Services	Projected Current Year 20	Most Recent Closed Year 20	Fiscal Year Ended 20	Fiscal Year Ended 20
	$	$	$	$

Fiscal Year : to

For the most recent closed year, estimate as closely as possible the percentages of fees for the following services :

Audits
Financial Institutions - Complete Appendix II	%
Construction/Real Estate	%
Manufacturing/Mercantile/Services	%
Government/Municipality	%
Non-profit	%
Pension/Profit Sharing	%
Other (Specify)	%
Subtotal	%
Accounting Services
Review	%
Compilation/Write-up/Bookkeeping Services	%
Subtotal	%
Tax Services
Individual/Corporate	%
Other (Specify)	%
Subtotal	%

Other Services
Computer Consulting	%
Management Consulting (description)	%
Projections and Forecasts (provide sample engagement letter)	%
Investment Advice - Complete Appendix VIII	%
Financial Planning - Complete Appendix VIII	%
Fiduciary/Trustee Services (includes administrator, executor, or ERISA trustee) - Complete appendix IV	%
Litigation Services	%
Other Services (description)	%
Subtotal	%
Total	100%

Does the firm provide any non-accounting services (i.e., EDP, Human Relations Consulting, etc.)? Yes No If yes. Collateral coverages may be available.

8 Within the past five (5) years, has the applicant, any member of the applicant's firm or any predecessor in business provided services to FINANCIAL INSTITUTIONS (defined as banks, credit unions, savings & loans, building & loan associations, savings associations or any other banking institution, subsidiary or affiliate thereof)? Yes No

If yes, please complete Appendix II, Financial Institutions.

9 Has the firm provided or does it anticipate providing professional services for SEC - regulated clients (as defined below) :
Yes No

1) an issuer making an initial filing, including amendments, under the Securities Act of 1933; 2) a registrant that files periodic reports with the Securities Exchange Commission (SEC) under the Investment Company Act of 1940 or the Securities Exchange Act of 1934 (except brokers or dealers registered only because of section 15(a) of that Act); 3) an issuer making an intrastate offering regulated by state Blue Sky laws;
an issuer of a private offering memorandum (PPM), Regulation D Debt or equity offering or any other exempt transaction or securities offering in which the applicant organized, arranged, promoted, participated in the structuring of, provided projections, forecasts or audits.

Complete Appendix V, Limited Partnership/Private Placement Memorandum for PPMs and Limited Partnerships only. For all other SEC-regulated clients, complete Appendix III, SEC Exposures.

10 Does any client represent 15% or more of your annual fees?
Yes No If so, what percent? %

If yes, please provide client industry, services provided by firm and length of time as a client

11 Do you have audit clients who are preparing to or have filed bankruptcy, insolvency or receivership proceedings within the last five (5) years in which a going concern or other written qualification was not expressed? Yes No

If yes, please provide date of bankruptcy, insolvency or dates of service :

Was an engagement letter used? Yes No

12 Within the past 12 months has the firm withdrawn from any engagements after services have commenced? Yes No

If yes, was a disengagement letter issued? Yes No

13 Does any member of the firm act as a fiduciary, trustee, power of attorney, guardian, executor, administrator or any other similar capacity including ERISA? Yes No

If yes, please complete Appendix IV, Fiduciary/Trust Information

14 Has the firm or any partner, principal, officer or employee within the last five (5) years :

Organized, arranged, promoted, participated in the structuring of, provided projections, forecasts or audits for tax shelters, private placements, limited partnerships, real estate syndicates, blind pools or other investments? Yes No
Participated in the preparation of offering material, prospectus or other sales literature?
Yes No
Acted as manager, partner or general partner of any investment partnership, limited partnership, tax shelter or other investment syndicate or venture? Yes No
If yes to a, b or c above, complete Appendix V, Limited Partnership/Private Placement Memorandum.
Made recommendations as to the sale or purchase of any specific investment vehicles, stocks, bonds, syndicates, partnerships or other securities? Yes No
Received commissions, fees or reciprocity for sale or promotion of computer hardware or software? Yes No
Provide written disclosure of potential conflicts of interest or lack of independence to clients who are investors, limited partners or who are otherwise participating in such ventures as listed above? Yes No

Part III : Outside Activities

15 a. Does any partner, principal or employed CPA of the firm act as a director/officer of any organization? Yes No(Excluding own firm and civic or professional organizations)

b. Does the firm or any partner, principal or employed CPA or spouse own, operated or manage any entity (excluding insured CPA firm), organization, corporation or enterprise, either for profit or not for profit? Yes No

If a or b are answered yes, complete Appendix VI, Outside Activities.

Part IV : Business Practices

16 a. Does the firm delegate work to other firms or outside technical experts? Yes No
If yes, describe the nature of the work, to whom it is delegated and the percentage of gross fees :

Do you utilize hold harmless agreements in the delegation of work? Yes No

Do you require certificates of insurance? Yes No

b. Is the firm performing any services as part of a joint venture? Yes No

If yes, provide name of other partner(s), nature and length of the engagement and responsibilities you have assumed

c. Is the firm providing service outside the United States? Yes No

If yes, describe :

17 a. What portion of your fees covered by single engagement letters? %

b. Are signed engagement letters received for all audit engagements? Yes No

c. How long has your firm been issuing engagement letters for audits?

d. Are engagement letters updated and re-signed annually? Yes No

e. Do you have a system to verify receipt of signed engagement letters? Yes No

Your firm may be eligible for a premium credit if you use engagement letters. Please provide a completed Engagement Letter Report Form and a sample letter for each service.

18 a. Within the past three(3) years, have you had a peer review or on-site quality review under the sponsorship of the AICPA, a state society or any other professional association? Yes No

b. Number of prior unqualified reviewers?

c. Is the firm scheduled for peer review or quality review? If so, when?
Yes No

d. Has the firm ever had a qualified or modified review? Yes No

If yes, please forward a copy of the noted deficiencies, as well as responses and corrections.

Firms which have completed an unqualified peer review/on-site quality review are eligible for premium credit. Please provide a copy of report and option rendered, including letters of comment, firm's response and invoice for cost of the peer review.

19 Does the firm's program for development and continuing professional education (CPE) of the professional staff exceed requirements? Yes No

Areas of specialization :

20 a. Are working papers reviewed by a partner other than the engagement partner?
Yes No

b. Are reports reviewed by a partner other than the engagement partner? Yes No

If no to a or b, describe your cold review process :

21 a. Does the firm have a written quality control document? Yes No

b. Does the firm use written procedure manuals? Yes No

c. Does the firm have written system for screening and evaluating new clients? Yes No

Part V : Claim History

22 Have you sued for fees in the past five years? Yes No

If yes, please list all outstanding suits showing amounts owed, date of suit, services rendered, current status, whether still a client and if an engagement letter was used.

23 Have any claims been made against the firm, its predecessors in business, acquired
firms or any of the present principals or partners or, to the knowledge of the firm,
against any past principal partner? Yes No

a) within the last 5 years and closed or Yes No

b) still open regardless of when the claim was first made. Yes No

Having inquired of all partners, principals and officers, are there any facts, circumstances, incidents, situations, conditions, disputes, prior acts, errors, omissions or any other matters which may result in a claim being made against the firm, its predecessors, acquired firms or past/present partners, principals, officers or employees?

Please complete Appendix VII, Supplemental Claim History for each of the following : All open claims All claims closed or settled within the last five (5) years All potential claims.

You should complete the information whether or not there was insurance coverage and whether or not the claim was settled within the deductible.

24 Has the firm or any partner, principal, officer or employee of the firm ever :

a. Has his/her certificate, license, or permit to practice suspended or revoked? Yes No

b. Been subjected to any disciplinary action or reprimand by any state board of accountancy, AICA or state society?
Yes No

c. Has the firm, its predecessors in business, acquired firms or any present or past partners, principals, officers or employed accountants ever been cautioned by the SEC of a State Department of Corporations with respect to any of its/their work, or been the subject of any SEC proceedings or investigation?
Yes No

If yes to any of the above questions, please explain.

25 Has the applicant, any predecessor or acquired firm had any professional liability insurance application denied, policy cancelled or non-renewed during the past five (5) years, for reasons other than an insurance company leaving the market? Yes No

If yes, please write explanation.

26 Applicant's professional liability insurance history for the last five (5) years :

Policy Period	Limits of Liability	Deductible	Premium	Insurance Company

a. Does the firm have coverage under the extended discovery provisions of any other policy?

If yes, provide the effective date and carrier :

b. What is the retroactive date on your current policy?

c. What was the effective date of the first claims-made professional liability policy covering the firm?

d. Have all subsequent policies been claims-made?

e. Have there been any interruptions in coverage since that date?

Yes No

Part VI :Coverage

27 Amount(s) of insurance and deductible for which quotations are sought.

Option 1

Option 2

Option 3

Limits :

Deductible Ranges :*

*If a deductible in excess of $25,000 (or in excess of 3% of the firm's current fees) is requested, please attach a current financial statement for the firm. Financial statements must be approved by A/pls+ prior to binding any such deductibles.

I have made specific inquiry of all partners, principals, and officers in the firm as to their knowledge of any circumstances which could potentially give rise to a claim against the firm at some point in the future. All have responded negatively to such inquiry, or have identified circumstances that have been reported to the firm's current insurer (if any) and listed on supplementary pages herein.

I agree that if the firm or any of its partners, principals or officers becomes aware of any information that would change answers furnished in this application subsequent to its completion, the firm will reveal such information in writing to the Company prior to the effective date of coverage.

On behalf of the applicant firm, I agree that this application, including any appendix(s), supplementary pages and other exhibits, is complete and correct to the best of my knowledge and belief. I understand that the application shall form the basis of the contract of insurance should the Company offer coverage and should the firm accept the Company’s quotation. I also understand that completion of this application does not bind the Company or broker to provide insurance.

Colorado Fraud Warning: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds, shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Florida Fraud Warning: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Kentucky Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

New York Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claims for each such violation.

Ohio Fraud Warning: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma Fraud Warning: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of any insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Pennsylvania Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claims containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Name :

Title :

Name of Contact Person :

Date of Application :

Taxpayer ID# :