PI-ACT-1953-5(05/10) Page 1 of 2
__________________________________________________________________________
Name of Insurance Company to which Application is made (herein called the “Insurer”)
ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION
PUBLIC COMPANY AUDIT SUPPLEMENT
Supplement No. 5
1. Full name of Applicant Firm:
2. Please list below all public companies which your firm has performed auditing services for within the past five (5)
years, with an entry for each annual engagement:
Name
Stock Symbol Audit Date Going Concern Type of Opinion
Issued
Rendered
Yes / No
2. Has your firm registered with the Public Company Accounting Oversight Board (PCAOB)? Yes No
3. Has your firm ever undergone a PCOAB investigation? Yes No
If yes, please use the separate page attached to the application to provide an explanation.
4. Does your firm have written audit procedures as regards to public company audit? Yes No
If yes, please use the separate page attached to the application to 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
