Fillable ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION - VIRGINIA (Philadelphia Insurance Companies)

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ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION - VIRGINIA (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.
1. Name of the Applicant:_____________________________________________________________________
1a. Applicant Firm’s Tax ID Number:__________________________________________
Please attach a sample of your letterhead to this application.
2. The Applicant Firm is a(n):
Individual
Other:__________________________________________
Partnership Professional Association
Professional Corporation LLC or LLP
Yes No
3. Is the Applicant Firm engaged in the practice of accountancy?
If no, please contact your agent before proceeding.
4. Applicant Firm’s principal location:
Address:_________________________________________________________________________________
City :_____________________________________________ State:_________ Zip Code:________________
6. When was the Applicant Firm established? _____________________________ (Month/Day/Year)
5. Applicant Firm’s mailing address:
Address:_________________________________________________________________________________
City :_____________________________________________ State:_________ Zip Code:________________
Not Applicable
7. If the Applicant Firm has been established less than six (6) years, please list:
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 INSURANCE
APPLICATION - VIRGINIA
Name of Insurance Company to which Application is made (herein called the “Insurer”)
PI-ACT-1953 VA (03/10)
Page 1 of 7
© 2015 Philadelphia Consolidated Holding Corp.
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_________________________________________________________________________________________
8. Does your firm practice from additional offices?
Yes No If yes, please attach a copy of the letterhead
for each satellite office.
Current fiscal year’s projected revenue: $_______________________________
________________________________ Total number of clients served in the past twelve (12) months:
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: $_______________________________
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-1953 VA (03/10)
Page 2 of 7
© 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. 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 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 $___________________________
15. Has the Applicant Firm, or any Predecessor Firm ever conducted SEC services or audits for any publicly held
companies?
Yes No If yes, please complete the Public Company Audit Supplement No. 5.
16. Within the past six (6) years have any of the Applicant Firm’s accountants served as a director, officer, or an
employee of any client; owned an equity interest in any client; or does any client represent more than twenty-five
(25) percent of the Applicant Firm’s revenues?
Yes No If yes, please provide the following for each:
Name of Client:______________________________________________________________________________
Nature of business:___________________________________________________________________________
Services provided:___________________________________________________________________________
Dollar Value of Interest$_____________
Person holding a position for this client:_____________________________ Title:_________________________
% of Firm’s revenue derived from the client:___ % Equity interest ___%
Name of Client:______________________________________________________________________________
Nature of business:___________________________________________________________________________
Services provided:___________________________________________________________________________
Dollar Value of Interest$_____________
Person holding a position for this client:_____________________________ Title:_________________________
% of Firm’s revenue derived from the client:___ % Equity interest ___%
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?
No
Name of Individual: _______________________________________ Profession: _________________________
Annual income derived from profession: $_____________________ Insurance Carrier:_____________________
Yes
To enter more information, please use the separate page attached to the application
PI-ACT-1953 VA (03/10)
Page 3 of 7
© 2015 Philadelphia Consolidated Holding Corp.
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________________________________________________________________________________________
________________________________________________________________________________________
No If yes, please provide details:
18. 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
19. 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.
19a. 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
19b. Please advise the total number of events which are applicable under 19. or 19a.:_____________________
No If yes, complete the Accountants
Professional Claim Supplement form No. 1 for each incident.
For all incidents listed in questions 19. or 19a., a separate Claim Supplement form No. 1 must be
completed.
Insurer: __________________________ Policy effective date: __________ Policy expiration date: ___________
Aggregate Limit: $______________________________ Per Claim Limit: $_________________________
Premium: $____________________ Deductible $ ___________________
20. Please provide the following information for the Applicant Firm’s/Predecessor Firm’s most recent professional
liability policy:
Yes No
If yes, what is the date? ___________________________________
20a. Does the Applicant Firm’s current policy have a retro-active date?
21. 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
Other: $_____________________ /
$500,000/$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
Deductibles
$1,000 $5,000
Other: $______________________
$3,000
$20,000
$2,000 $7,500 $25,000
$2,500 $10,000
$15,000
22.
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
PI-ACT-1953 VA (03/10)
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© 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 19. or 19a. 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-1953 VA (03/10)
Page 5 of 7
© 2015 Philadelphia Consolidated Holding Corp.
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FRAUD STATEMENT AND SIGNATURE SECTIONS
RESIDENTS OF VIRGINIA APPLICANTS: “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 AND DENIAL OF INSURANCE BENEFITS.”
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
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)
ADDRESS (STREET, CITY, STATE, ZIP)
PI-ACT-1953 VA (03/10)
Page 6 of 7
© 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-1953 VA (03/10)
Page 7 of 7
© 2015 Philadelphia Consolidated Holding Corp.
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Completed 7 November 2020

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