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

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PI-ACT-1953-3(05/10) Page 1 of 3
__________________________________________________________________________
Name of Insurance Company to which Application is made (herein called the “Insurer”)
ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION
SEC INFORMATION SUPPLEMENT
Supplement No. 3
Please complete this supplement if directed by the main-form application, or another supplement. If space
is insufficient to answer any question completely, attach a separate sheet.
1. Full name of the Applicant Firm:
2. List the names of all accountants engaged in the securities practice:
Name: Years of SEC experience:
Name: Years of SEC experience:
Name: Years of SEC experience:
Name: Years of SEC experience:
3. Gross income derived from the securities practice:
Last fiscal year: $ Anticipated next fiscal year: $
4. List all securities offerings, private placements and limited partnerships involved within the past five (5) years:
Client: Industry:
Year: Primary or Secondary:
Client: Industry:
Year: Primary or Secondary:
Client: Industry:
Year: Primary or Secondary:
5. Other than primary or secondary offerings, describe any other work involving securities practice:
Client: Industry:
Number of shareholders: 10K : Yes No 10Q: Yes No
Client: Industry:
Number of shareholders: 10K : Yes No 10Q:
Yes No
Client:
Industry:
Number of shareholders
: 10K : Yes No 10Q:
Yes No
Clear Application
Print Application
PI-ACT-1953-3(05/10) Page 2 of 3
5a. Is your Firm’s wo
rk included in a 10K or 10Q report that another Firm produces? Yes No
Client: Industry:
Number of shareholders: 10K : Yes No 10Q: Yes No
Client: Industry:
Number of shareholders: 10K : Yes No 10Q: Yes No
Client: Industry:
Number of shareholders: 10K : Yes No 10Q: Yes No
6. Has the Applicant Firm (including any Predecessor Firms), or any past or present employees or partners of the
Applicant Firm been subject to any disciplinary proceedings before the SEC or state securities authorities within
the past ten (10) years? Yes No If yes, please provide an explanation.
7. Does your Firm use engagement letters on all SEC engagements? Yes No
8. Does your Firm have written client acceptance procedures? Yes No
If yes, please provide an explanation.
9. Do any of your SEC clients have a negative net worth? Yes No
If yes, please provide an explanation.
10. Has there been a change in the controlling ownership of the client company(ies) during the last fiscal year?
Yes No If yes, please provide an explanation.
11. Has there been a change in the ex
ecutive management of the client company(ies) during
the last fiscal year?
Yes No If yes, please provide an explanation.
I understa
nd informatio
n 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
Clear Application
Print Application
PI-ACT-1953-3(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
Clear Application
Print Application
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ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION SEC INFORMATION SUPPLEMENT (Philadelphia Insurance Companies)

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Completed 7 November 2020

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