PI-ACT-1953-4(05/10) Page 1 of 2
__________________________________________________________________________
Name of Insurance Company to which Application is made (herein called the “Insurer”)
ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION
FINANCIAL INSTITUTION SUPPLEMENT
Supplement No. 4
Please complete this supplement if directed by the main-form Application. Please copy this form and fill
out a separate form for each engagement. If space is insufficient to answer any question completely, attach
a separate sheet.
1. Full name of Applicant Firm:___________________________________________________________________
2. Complete the following if your firm has performed a
udits and/or directors examinations for depository institutions
insured by the FDIC, NCUA (credit unions) or state insurance funds within the past five (5) years.
Name:______________________________________________________________________________________
Address:_______
_____________________________________________________________________________
Type of Institution:__________________________ Years:______ Type of Engagement:__
___________________
Equity/Asset ratio as of the last quarter_________________________ Accounting Fees: $____________________
Name:______________________________________________________________________________________
Address:_______
_____________________________________________________________________________
Type of Institution:__________________________ Years:______ Type of Engagement:__
___________________
Equity/Asset ratio as of the last quarter_________________________Accounting Fees: $____________________
3. Has any member (or former member) of your firm:
a. Had unsecured loan commitments with the above institution(s) ?
Yes No
If yes, please provide an explanation: ___________________________________________________________
___________________________________________________________________________________________
b. Held stock or other financial interest in the above institution(s)?
Yes No
If yes, what is the equity percentage? ______________________%
c. Acted as a director or officer of the above institution(s)?
Yes No
d. Been a member of the following internal committees of the above institution(s):
Executive Committee Loan Committee Audit Committee Other (describe)________________________
4. Does your firm have a policy prohibiting any member from acting as a director or officer of a financial institution
which is also a client of the firm?
Yes No If no, please provide an explanation._______________________
___________________________________________________________________________________________
___________________________________________________________________________________________
I understand 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
