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

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ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE RENEWAL APPLICATION - FLORIDA (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.
Please attach a sample of your letterhead to this application.
1. Name of the Applicant:
2. Address:
3. 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:
3a. Most recently ended fiscal year’s revenue: $
Current fiscal year’s projected revenue: $
ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE
RENEWAL APPLICATION - FLORIDA
Name of Insurance Company to which Application is made (herein called the “Insurer”)
4. Risk Management Contact: Ri
sk Management’s Phone:
Risk Management Email:
5. Since your last application furnished to us, has any member of the Applicant Firm or any
Predecessor Firm been the subject of a complaint, disciplinary action or reprimand by any
s
tate 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.
6. Since your last application furnished to us 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 become
insolvent?
Yes
No
e. for which they were an officer, director, or general counsel? Yes No
If any part(s) of question 6 are answered yes, complete Financial Institution
Supplement form No. 4.
ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE
RENEWAL APPLICATION -FLORIDA
Name of Insurance Company to which Application is made (herein called the “Insurer”)
City: State:
Zip Code:
Website:
Telephone Number:
PI-ACT-2004R FL (03/10)
Page 1 of 6
© 2015 Philadelphia Consolidated Holding Corp.
10/2015
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7. Area of Practice: Please identify the Applicant Firm’s areas of practice with the numb
er representing the
percentage of gross income derived fro
m 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
8. In the past twelve (12) months, how many suits for collection of fees have been filed by the Applican
t Firm or
Predecessor Firms during the pa
st 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: $
9. In the past twelve (12) months has the Applicant Firm, or any Predecessor Firm conducted SEC se
rvices or
audits for any publicly held companies
?
Yes No If yes, please complete the Public Company Audit
Supplement No. 5
10. In the past year, has the Applicant Firm undergone any peer or quality review sponsored by the AICPA or any
state society of CPA’s?
Yes No If yes, the results were: Unqualified Qualified, Modified or Adverse
11. After inquiry, are any individuals of the Applicant Firm aware of any professiona
l liability claims made against
them, the Applicant Firm or a Predece
ssor Firm, which have not already been reported to us, on an application,
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.
11a. After inquiry, are any individuals of the Applicant Firm aware of any actual or alleged act, error, omissio
n,
incident or circumstance, which migh
t reasonably result in a claim against them, the Applicant Firm or against any
members of the Predecessor Firm, which have not already been reported to us?
Yes No If yes, complete
the Accountants Professional Claim Supplement form No. 1 for each incident.
11b. Please advise the total number of incidents which are applicabl
e under 11. or 11a:
For all incidents listed in questions 1. or 1a., a separate Cla
im Supplement No.1 form must be
completed.
PI-ACT-2004R FL (03/10)
Page 2 of 6
© 2015 Philadelphia Consolidated Holding Corp.
10/2015
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$100,000/$300,000 $1,000,000/$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 Other: $ /
$500,000/$1,000,000 $
Deductibles
$1,000 $5,000 $20,000
$2,000 $7,500 $25,000
$2,500 $10,000 Other: $
$3,000 $15,000
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12. 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
PI-ACT-2004R FL (03/10)
Page 3 of 6
© 2015 Philadelphia Consolidated Holding Corp.
10/2015
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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 10., or 10a.; 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-2004R FL (03/10)
Page 4 of 6
© 2015 Philadelphia Consolidated Holding Corp.
10/2015
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FRAUD STATEMENT AND SIGNATURE SECTIONS
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
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION
FORINSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND
SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A
FRAUDULENT INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL
PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION).
(NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE
INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN
PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION
TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY
INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN
INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A
POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT
WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO
DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY
INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS
GUILTY OF A FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR
PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR
ANY AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE
RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT
PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN
MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: 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 OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATOIN FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR
CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT
INSURANCE ACT, WHICH IS A CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE
STATE VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
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 Ris
k, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
PI-ACT-2004R FL (03/10)
Page 5 of 6
© 2015 Philadelphia Consolidated Holding Corp.
10/2015
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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-2004R FL (03/10)
Page 6 of 6
© 2015 Philadelphia Consolidated Holding Corp.
10/2015
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ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE RENEWAL APPLICATION - FLORIDA (Philadelphia Insurance Companies)

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Completed 7 November 2020

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