Fill - Free fillable ACCOUNTANTS PROFESSIONAL LIABILITY ,1685$1&( APPLICATION 0,66285, (Philadelphia Insurance Companies) PDF form

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__________________________________________________________________________

NOTICE: This professional liability coverage is provided on a claims-made basis; therefore, only claims which are

first made against you, and reported to the Company, during the policy term, any subsequent renewal of this

policy or any extended reporting period are covered, subject to policy provisions.

Please attach a sample of your letterhead to this application.

1. Name of the Applicant:_____________________________________________________________________

1a. Applicant Firm’s Tax ID Number: Telephone No.:

2. The Applicant Firm is a(n):

Individual Partnership Professional Association

Professional Corporation LLC or LLP Other:__________________________________________

3. Is the Applicant Firm engaged in the practice of accountancy?

Yes No

If no, please contact your agent before proceeding.

4. Applicant Firm’s principal location:

Address:_________________________________________________________________________________

City :_____________________________________________ State:_________ Zip Code:________________

5. Applicant Firm’s mailing address:

Address:_________________________________________________________________________________

City :_____________________________________________ State:_________ Zip Code:________________

6. When was the Applicant Firm established? _____________________________ (Month/Day/Year)

7. If the Applicant Firm has been established less than six (6)years, please list:

Not Applicable

A. Name of the Predecessor Firm:_________________________________________ Date Formed:__/___/___

Percent owned by the current members of the Applicant firm: ______________%

What is the current status of the Firm :

Dissolved Changed the firm name Continues to exist

B. Name of the Predecessor Firm:_________________________________________ Date Formed:__/___/___

Percent owned by the current members of the Applicant firm: _______________%

What is the current status of the Firm :

Dissolved Changed the Firm Name Continues to exist

To enter more information, please use the separate page attached to the application

ACCOUNTANTS PROFESSIONAL LIABILITY ,1685$1&(

APPLICATION 0,66285,

Name of Insurance Company to which Application is made (herein called the “Insurer”)

PI-ACT-2005-MO (03/10)

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8. Does your firm pra

ctice f

rom additional offices?

Yes No If yes, please attach a copy of the letterhead

for each satellite office.

9. Please list the Applicant Firm’s staff breakdown:

Number of full time equivalent CPA’s: ________________________________

Number of full time equivalent non CPA Accounting Professionals: ________________________________

Number of full time equivalent support staff: ________________________________

9a. Most recently ended fiscal year’s revenue: $_______________________________

Current fiscal year’s projected revenue: $_______________________________

Total number of clients served in the past twelve (12) months: ________________________________

10. Has any member of the Applicant Firm or any Predecessor Firm been the subject of a complaint, disciplinary

action or reprimand by any state board, the SEC, I.R.S., governmental regulatory or tax authorities, or any

accounting society?

Yes No If yes, please use the separate page attached to the application to

provide an explanation.

11. Does the Applicant Firm share office space with professionals/firms other than those listed in question

eight(8)?

Yes No If no, skip to question 12

11a. If the Applicant Firm shares an office with other professionals does your firm separate files, employ separate

support staff and present itself as an independent practice to the public?

Yes No

11b.The name of the professionals/firm with whom the Applicant Firm shares an office is:

_________________________________________________________________________________________

12. Area of Practice: Please identify the Applicant Firm’s areas of practice with the number representing the

percentage of gross income derived from that area during the past year. The total of these must be one

hundred (100) percent and represent all areas of practice.

Area of Practice %

Engagement

Letters Used

Public Company Audit * Yes No

Other Audit * Yes No

Other Attest/Assurance Services (Describe the services provided on a

separate sheet)

Yes No

Review Yes No

Compilation Yes No

Bookkeeping Yes No

Individual Tax Yes No

Business Tax Yes No

Consulting Services (Describe the services provided on a separate sheet) Yes No

Estate Tax Yes No

Fiduciary Services Yes No

Litigation Support Yes No

Securities Activities ** Yes No

Forecasts/Projections Yes No

Business Valuations Yes No

Business Planning (Describe the services provided on a separate sheet) Yes No

Personal Financial Planning and Investment Advisory Services (Describe

the services provided on a separate sheet)

Yes No

Other (Describe the services provided on a separate sheet) Yes No

* If any percentage is indicated, complete the Audit Engagements Supplement form No. 2

** If any percentage is indicated, complete the SEC Information Supplement form No. 3

PI-ACT-2005-MO (03/10)

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13. Have any individuals in the Applicant Firm, or any Predecessor Firm, in the past two (2) years provided these

services to any financial institution client:

a. Regulatory, securities, or compliance services?

Yes No If yes, complete SEC Information Supplement

No. 3

b. Services for an institution in which an Applicant member held an equity or management interest?

Yes No

c. Whose deposits are not insured by a government agency such as the FDIC or NCUA?

Yes No

d. Which was either in its formative stage, or which has at any point since become insolvent?

Yes No

e. For which they were an officer, director, or general counsel?

Yes No

If any part(s) of question 13 are answered yes, complete Financial Institution Supplement form No. 4

14. How many suits for collection of fees have been filed by the Applicant Firm or Predecessor Firms during the

past two (2) years? ________________ How many of these suits have been resolved successfully?__________

Dollar amount of fee suits last year: $___________________________

Dollar amount of suits for the previous year: $___________________________

15. Has the Applicant Firm, or any Predecessor Firm ever conducted SEC services or audits for any publicly held

companies?

Yes No If yes, please complete the Public Company Audit Supplement No. 5.

16. Within the past six (6) years have any of the Applicant Firm’s accountants served as a director, officer, or an

employee of any client; owned an equity interest in any client; or does any client represent more than twenty-five

(25) percent of the Applicant Firm’s revenues?

Yes No If yes, please provide the following for each:

Name of Client:______________________________________________________________________________

Nature of business:___________________________________________________________________________

Services provided:___________________________________________________________________________

% of Firm’s revenue derived from the client:___% Equity interest ___% Dollar Value of Interest$_____________

Person holding a position for this client:_____________________________ Title:_________________________

Name of Client:______________________________________________________________________________

Nature of business:___________________________________________________________________________

Services provided:___________________________________________________________________________

% of Firm’s revenue derived from the client:___% Equity interest ___% Dollar Value of Interest$_____________

Person holding a position for this client:_____________________________ Title:_________________________

To enter more information, please use the separate page attached to the application

17. Does any member of the Applicant Firm hold any professional license other than for accountancy?

Yes No

Name of Individual: _______________________________________ Profession: _________________________

Annual income derived from profession: $_____________________ Insurance Carrier:_____________________

To ente

r more information, please use the separate page attached to the a

pplication

PI-ACT-2005-MO (03/10)

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18. Check Organizations with which the Applicant Firm staff is affiliated:

American Institute of Certified Public Accountants Missouri Society of CPA’s

19. In the past three (3) years, has the Applicant Firm undergone any peer or quality review sponsored by the

AICPA or any state society of CPA’s?

Yes No If yes, the results were:

Unqualified Qualified, Modified or Adverse

20. After inquiry, are any individuals of the Applicant Firm aware of any professional liability claims made against

them, the Applicant Firm or a Predecessor Firm in the past six (6) years, including those which may have been

made against them while with a Prior Firm?

Yes No If yes, complete the Accountants Professional

Claim Supplement form No. 1 for each incident.

20a. After inquiry, are any individuals of the Applicant Firm aware of any actual or alleged act, error, omission,

incident or circumstance, which might reasonably result in a claim against them, the Applicant Firm or against any

members of a Predecessor Firm in the past six (6) years?

Yes No If yes, complete the Accountants

Professional Claim Supplement form No. 1 for each incident.

20b. Please advise the total number of incidents which are applicable under 20. or 20a.:____________________

For all incidents listed in questions 20. or 20a., a separate Claim Supplement form No. 1 must be

completed.

21. Please provide the following information for the Applicant Firm’s/Predecessor Firm’s most recent professional

liability policy:

Insurer: __________________________ Policy effective date: __________ Policy expiration date: ___________

Per Claim Limit: $_________________________ Aggregate Limit: $_____________________

_________

Deductible $ ___________________ Premium: $____________________

21a. Does the Applicant Firm’s current policy have a retro-active date?

Yes No

If yes, what is the date? ___________________________________

22. Please note that the coverage will be offered only at the company’s election. Coverage terms offered are also

subject to determination by the Insurer. Please indicate the limit and deductible for which you wish to receive a

quotation:

Limits

$100,000/$300,000 $1,000,000/$1,000,000 $3,000,000/$3,000,000

$250,000/$500,000 $1,000,000/$2,000,000 $4,000,000/$4,000,000

$500,000/$500,000 $2,000,000/$4,000,000 Other: $_____________________ /

$500,000/$1,000,000 $_____________________

Deductibles

$1,000 $5,000 $20,000

$2,000 $7,500 $25,000

$2,500 $10,000 Other: $______________________

$3,000 $15,000

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23.

Risk Management Contact:

sk Management’s Phone:

Risk Management Email:

PI-ACT-2005-MO (03/10)

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REPRESENTATIONS: I/We affirm that the information contained here and in any addendum is true to the best of

my/our knowledge and that it shall be the basis of the policy of insurance and deemed incorporated therein,

should the Company evidence its acceptance of this application by issuance of a policy. I/We hereby authorize

the release of claim information from any prior insurer to the Company or its representatives.

NOTICE

1. Any claim or incident:

a) reported on question 20. or 20a. or

b) of which any member of the applicant firm has knowledge prior to policy inception will not be afforded

coverage under any policy which may subsequently be issued by and of the Philadelphia Insurance

Companies.

2. Failure to report to your current insurance company any:

a) claim made against you during your current policy term; or

b) fact, circumstance or incident of which your accountants are aware, which may give rise to a claim

BEFORE policy expiration, may create a lack of coverage.

PI-ACT-2005-MO (03/10)

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FRAUD STATEMENT AND SIGNATURE SECTIONS

The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge

and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this

Application) are true and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information

in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the

Company may modify or withdraw the quote or binder.

The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.

*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company

FRAUD NOTICE STATEMENTS

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION

FORINSURANCE 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 THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A

FRAUDULENT INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL

PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION).

(NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, RI, TN, VA, VT, WA AND WV).

APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR

FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE

INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN

PRISON.

APPLICABLE IN COLORADO: 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.

APPLICABLE IN FLORIDA AND OKLAHOMA: 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 (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).

APPLICABLE IN KANSAS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR

PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR

ANY AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE

RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT

PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN

MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING,

INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT.

APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR

MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY

INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.

APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER

PERSON FILES AN APPLICATOIN 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 BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE

STATE VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

NAME (PLEASE PRINT/TYPE) TITLE

(MUST BE SIGNED BY THE PRINCIPAL, PARTNER OR

OFFICER)

____________________________________________________

SIGNATURE DATE

SECTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT

PRODUCER AGENCY

(If this is a Florida Risk, Producer means Florida Licensed Agent)

PRODUCER LICENSE NUMBER

(If this a Florida Risk, Producer means Florida Licensed Agent)

ADDR

ESS (STREET, CITY, STATE, ZIP)

PI-ACT-2005-MO (03/10)

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ADDITIONAL INFORMATION

This page may be used to provide additional information to any question on this application. Please

identify the question number to which you are referring.

__________________________________________

Signature Date

PI-ACT-2005-MO (03/10)

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