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ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION CLAIM INFORMATION SUPPLEMENT (Philadelphia Insurance Companies)

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PI-ACT-1953-1(05/10) Page 1 of 3
__________________________________________________________________________
Name of Insurance Company to which Application is made (herein called the “Insurer”)
ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION
CLAIM INFORMATION SUPPLEMENT
Supplement No. 1
Submit one form for each claim or incident. If space is insufficient to answer any question completely,
please attach a separate page to the application.
1. Full name of the Applicant Firm: ________________________________________________________________
2. Full name of the firm which repo
rted the claim (if different from above): _________________________________
___________________________________________________________________________________________
3. Full name of the Claimant: ____________________________________________________________________
4. Indicate whether:
Claim / Suit Incident / Potential Claim
5. Date / Period of alleged error: _______________________________________________________________
6. Date the Claim was reported to the insurance carrier: _______________________________________________
7. Other parties against which this Claim is made: ___________________________________________________
8. This claim is:
OPEN CLOSED
9. If CLOSED, indicate the date closed: ____________________________________________________________
10. Please complete the following:
If Claim is still open:
A. Claimants settlement demand: $_____________________________________
B. Defendant’s offer for settlement: $_____________________________________
C. Insurance Company’s loss reserve $_____________________________________
D. Deductible: $_____________________________________
E. Amounts paid to date: $_____________________________________
If claim is closed:
A. Loss paid in excess of deductible: $_____________________________________
B. Expenses paid in excess of deductible: $_____________________________________
C. Deductible: $_____________________________________
D. Settlement reached via:
Court Judgment Formal Mediation/Arbitration Proceeding Out of Court Settlement
Note: If information is not available, please provide a copy of the suit papers.
11. Name of Insurance Company: ________________________________________________________________
12 Claim Number:_____________________________________________________________________________
Print Application
Clear Application
PI-ACT-1953-1(05/10) Page 2 of 3
13. De
scription of claim/ incident:
A. Provide a full description of the engagement, the events leading up to the claim, allegation asserted, against
your firm and the current status of the matter. Please indicate if the claimant was your client. If no, fully explain
claimant’s relationship to client:________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
B. Was an engagement letter used?
Yes No
C. What action has your firm taken to prevent a recurrence of such a claim in the future? _____________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
D. Did this incident or claim follow or result from an action to collect fees?
Yes No
I understand that the information submitted herein becomes a part of my Philadelphia Insurance
Companies Accountants Professional Liability Application and is subject to the same conditions as stated
on the application.
__________________________________________ _____________________________________________
Name (Please Print) Title (Must be Partner or Officer)
__________________________________________ _____________________________________________
Signature Date
Print Application
Clear Application
PI-ACT-1953-1(05/10) Page 3 of 3
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
Print Application
Clear Application
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ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION CLAIM INFORMATION SUPPLEMENT (Philadelphia Insurance Companies)

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Completed 7 November 2020

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