Fillable ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION (Philadelphia Insurance Companies)

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ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION (Philadelphia Insurance Companies)

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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 Number:
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 e
stablished 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
Name of Insurance Company to which Application is made (herein called the “Insurer”)
ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE
APPLICATION
PI-ACT-2005 (03/10)
Page 1 of 8
© 2015 Philadelphia Consolidated Holding Corp.
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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, discip
linary
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 separat
e 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 Applican
t 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 (03/10)
Page 2 of 8
© 2015 Philadelphia Consolidated Holding Corp.
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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. Regul
atory, 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 been 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: $ $___
________________________
15. Has the Applicant Firm, or any Predecessor Firm ever conducted SEC services or audits for any publicly held
comp
anies?
Yes No If yes, please complete the Public Company Audit Supplement No. 5.
15a. Has the Applicant Firm or any Predecessor Firm received equity or any other non-mon
etary compensation
for the rendering of accounting services?
Yes No If yes, wa
s this only on tax engagements? Yes No
15b. Has the Applicant Firm arranged, coordinated or
managed any investment venture?
Yes No If yes,
please use the separate page attached to the application to provide an explanation.
16. Within the past six (6) years have any of the Applicant Firm’s accountants served as a director, officer, or an
employee of any client; owned an equity interest in any client; or does any client represent more than twenty-five
(25) percent of the Applicant Firm’s revenues?
Yes No If yes, please provide the following for each:
Name of Client:______________________________________________________________________________
Nature of business:___________________________________________________________________________
Services provided:___________________________________________________________________________
% of Firm’s revenue derived from the client:___% Equity interest ___% Dollar Value of Interest$_____________
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
PI-ACT-2005 (03/10)
Page 3 of 8
© 2015 Philadelphia Consolidated Holding Corp.
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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 application
18. Within the past 3 years, has the Applicant Firm or Predecessor Firm or any affiliated entity thereof rendered
audit or attest services for a business client, for which either the client or a parent of the client subsequently
declared or filed bankruptcy, defaulted on a debt obligation, or became insolvent?
Yes No If yes, please
complete the following:
Name of Client:_________________________________________ Client industry:________________________
Type of services
rendered:____________________________________________________
_________________
Dates of your service:________________________________________ Going concern reference:
Yes No
Date of bankruptcy, insolvency or default:_________________________________________________________
To enter more information, please use the separate page attached to the application
19. During the past six (6) years, has any insurer of the Applicant Firm , Predecessor Firm or Prior Firm canceled
or refused to renew professional liability insurance for any reason other than the carrier’s withdrawal from the
market?
Yes No If yes, please provide details:
________________________________________________________________________________________
___________________
_____________________________________________________________________
20.
In the past three (3) years, has the Applicant Firm undergone any peer or quality review sponsored for the
AICPA or any state society of CPA's
Yes No If y
es, the results were:
Unqualified Qualified, Modified or Adverse
21. After inquiry, are any in
dividuals of the Applicant Firm aware of any professional liability claims made against
them, the Applicant Firm or a Prede
cessor Firm in the past six (6) years, including those whic
h may have been
made against them while with a Prior Firms? Yes
No If
yes, complete the Accountants Professional
Claim Supplement form No. 1 for each incident.
21a. After inquiry, are any individuals of the Applicant Firm aware of any actual or alleged act, error, omissi
on,
incident or circumstance, which might reasonably re
sult in a claim against them, the Applicant Firm or against
any members of a Prede
cessor Firm in the past six (6) years?
Yes No If
yes, complete the Accountants
Professional Claim Supplement form No. 1 for each incident.
21b. Please a
d
vise the tota
l numbe
r of events whi
ch a
r
e appli
c
a
ble
unde
r 21. or
21a.:___
___
_
____
____
___
___
For all incidents listed in question
s
2
1
. or 21a., a separ
ate
Cla
i
m Supplement fo
rm No.
1 must be
completed.
22.
Please p
r
ovide 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: $____________________
22a. Does the Applicant Firm’s current policy have a retro-active date?
Yes No
If yes, what is the date? ___________________________________
PI-ACT-2005 (03/10)
Page 4 of 8
© 2015 Philadelphia Consolidated Holding Corp.
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23.
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
24.
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
PI-ACT-2005 (03/10)
Page 5 of 8
© 2015 Philadelphia Consolidated Holding Corp.
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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 21. or 21a. 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 (03/10)
Page 6 of 8
© 2015 Philadelphia Consolidated Holding Corp.
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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)
PRO
DUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
PI-ACT-2005 (03/10)
Page 7 of 8
© 2015 Philadelphia Consolidated Holding Corp.
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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 (03/10)
Page 8 of 8
© 2015 Philadelphia Consolidated Holding Corp.
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ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION (Philadelphia Insurance Companies)

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