Fillable Accountants Professional Liability Application

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Accountants Professional Liability Application

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The Accountants Professional Liability Application form is 17 pages long and contains:

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  • 154 check-boxes
  • 208 other fields

Country of origin: US
File type: PDF

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Page 1 of 11
ACCOUNTANTS – PROFESSIONAL LIABILITY INSURANCE APPLICATION
1. Legal name of the business who is the primary applicant and will be the first named insured listed on the policy:
2. Please list all other business/dba names for which you are seeking coverage under this policy:
3. Corporation Individual Partnership Municipality For Profit Joint Venture
Other:
4. Please list any names of other entities that you own or manage or that you do business under (such entities are not
requesting coverage under this policy):
5. Primary location address:
6. County of primary location: Date business originally established:
7. Total number of branches? List all addresses for additional branches:
8. What is your web-site address? www.
9. What is your phone number?
10. Has the name or ownership of the entity changed or has any other business been purchased, Yes No
merged or consolidated with the entity within the last 5 years?
11. Does any entity own or control your business or does your business own or control any entity? Yes No
12. During the past five years, has your name been changed or has any other business purchased, Yes No
merged or consolidated with you?
For questions 9-11, please fully explain any “yes” response, including the names, dates, and revenue impact involved:
13. Please list any associations of which you are a member:
1. Firm Staff (include contract and per diem employees who work 500 or more hours per year):
CPAs Non-CPAs Total
Owners, Partners, Officers
All Other Accounting or Tax Professionals
Other Consulting Professionals (not included above)
Administrative Staff
TOTAL
2. Has the staff size of the Firm changed +/- 25% during the past three years? Yes No
If “Yes”, please explain.
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 11
3. Based on the Firm’s fiscal year-end data, provide the following gross revenue figures:
Next Fiscal Year
(Projected)
Current Fiscal Year
(Estimated)
Last Fiscal Year Previous Fiscal Year
$ $ $ $
4. Percentage of revenue from the Firm’s largest clients (including related entities):
Largest ________% Second Largest _________%
For those clients representing 20% or more of the Firm’s revenue, please list for each:
Client Name
Client Industry
Services Performed
Length of Time as a Client
Describe how Firm maintains independence
Client Name
Client Industry
Services Performed
Length of Time as a Client
Describe how Firm maintains independence
Client Name
Client Industry
Services Performed
Length of Time as a Client
Describe how Firm maintains independence
5. Approximately what percentage of the Firm’s revenue is derived from the areas listed below? (Please indicate whether
or not engagement letters are used for each service area listed below.)
Service Area % of
Revenue
Engagement
Letter Used
Service Area % of
Revenue
Engagement
Letter Used
Accounting/Bookkeeping
• Accounting/Bookkeeping
% Yes No
Special Services
• Client Funds Controlled
• Non-Trustee Fiduciary
or Administrative
Responsibility – ERISA,
Pension & Benefit Plans,
ESOPs, Ins. Co.’s, Hedge
Funds, Other
Investment Co.’s
• Executor/Trustee/
Receiver
• Investment/Financial
Planning
%
%
%
%
Yes No
Yes No
Yes No
Yes No
Attestation
• Audit
• Non-Public
• Public
(Please complete an Audit Services
Supplemental Application if any
audit work performed.)
• Agreed Upon Procedures
• Review
• Compilation
%
%
%
%
%
%
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Page 3 of 11
• SEC-Section 404
Services
• SEC Work other than
Audit Section 404 Work
or Tax
%
%
Yes No
Yes No
Consulting
• Merger & Acquisition
• Computer Related
Services
• Litigation Support
• Management
Consulting/ Business
Planning
• Projections/Forecasts
•
Valuations
%
%
%
%
%
%
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Tax
• Business Tax
• Estate Tax
• Individual Tax
%
%
%
Yes No
Yes No
Yes No
Other
• Other (Please describe)
% Yes No
TOTAL ADDS TO 100%
100%
6. Does the Firm, or any Firm member provide:
a. Personal tax or other services to any individual client that has an annual income in Yes No
excess of $5 million?
b. Any attest services to any private company with annual sales of more than $250 million? Yes No
If “Yes” to a. or b. above, please provide the following:
Client Name
Client Industry
Services Provided
Length of Time as a Client
Client Name
Client Industry
Services Provided
Length of Time as a Client
Client Name
Client Industry
Services Provided
Length of Time as a Client
7. Has the Firm, any Firm member of spouse, within the past five (5) years:
a. Held an equity interest in, operated, or managed any entity (excluding the Firm) for Yes No
whom the Firm provided professional services?
b. Acted as a director, officer or exercised any form of managerial control over any entity Yes No
(excluding the Firm), for whom the Firm provided professional services?
If “Yes”, please describe.
Page 4 of 11
8. Has the Firm, or any Firm member, acted as trustee, co-trustee, executor, receiver, Yes No
administrator or personal representative, other than for life insurance trusts or trusts with
less than $500,000 in assets?
If “Yes”, please explain.
9. Does the Firm, or any Firm member, control or distribute client funds, other than as trustee Yes No
or executor?
If “Yes”, please explain.
10. Has the Firm, its predecessors, or affiliates, within the past five (5) years:
a. Performed audits for or provided consulting services to SEC-regulated entities (other Yes No
than broker/dealers who are not publicly traded)?
b. Performed services, or consented to the use of the Firm’s work product, in connection Yes No
with public or private offerings of securities, real estate, or other investments?
11. Is the Firm in the process of or planning to bid on any new engagements for a publicly held Yes No
company, its subsidiaries or its employee benefit plans?
If Yes, please describe.
12. Has the Firm, its predecessors or affiliates, within the past five (5) years performed services Yes No
for unregistered investment vehicles such as hedge funds, real estate or investment syndicates,
limited liability companies or partnerships (limited or general)?
If Yes, please describe.
13. Has the Firm, its predecessors or affiliates, within the past three (3) years:
a. Arranged debt or equity financing or acted as a business broker? Yes No
b. Acted as a mortgage agent/broker? Yes No
c. Performed actuarial services? Yes No
If “Yes” to a., b., or c. above, provide a detailed description of services performed for each such client, including a
sample engagement letter for these services.
14. Has the Firm, its predecessors or affiliates, currently, or within the past five (5) years:
a. Organized, sold, acted as sales promoter or sales agent for, or participated in the Yes No
management of or general partner for any real estate or other investment syndicate,
limited liability company (“LLC”) or partnership (limited or general)?
b. Received commission, finder fees, reciprocity or participation from sellers or promoters Yes No
of an investment, tax, shelter, securities, insurance products, or real estate?
Page 5 of 11
c. Organized, sold, acted as sale promoter or sales agent for, prepared any promotional sales Yes No
materials for, provided any tax advice, counsel or opinions with respect to, any “reportable
transaction” as defined in Treasury Regulation §1.6011-4(b), or any 1031 Like_Kind Exchanges?
d. Organized, sold, acted as sale promoter or sales agent for, prepared any promotional sales Yes No
materials for, provided any tax advice, counsel or opinions with respect to, or prepared or
assisted in preparing any income, gift or estate tax returns incorporating or reporting a tax
shelter or other tax advantaged investment which provided taxable income exclusions or tax
deductions exceeding $500,000 in any one tax year?
If “Yes” to a., b., c., or d. above, please explain.
15. (a) How many suits for the collection of fees have been filed by the firm during the past 24 months?
(b) How many of these suits have been resolved successfully? How many are still open?
16. Indicate what loss prevention tools your Firm requires Firm members to use:
a. Engagement letters are updated:
Annually for all engagements Annually for attest engagements
As engagements changes Evergreen (not updated)
Other: Not used
b. Second person/partner review of:
Attest services Tax Services
All services Other:
No second person/partner review of any services
c. Checklists:
AICPA PPC
Other: Not used or not applicable
d. Client screening procedures:
New clients prior to acceptance Existing clients
Both None
e. Do engagement letters contain ADR (Alternative Dispute Resolution) or Limitation of Yes No
Liability clauses?
If “Yes”, what is the liquidated damages amount stipulated in your engagement letter?
$
f. Does Firm have disengagement procedures for terminating client relationships? Yes No
g. Are declination/non-engagement letters used on all matters declined by the Firm? Yes No
If “No”, please explain:
h. Other loss prevention tools/procedures, please describe:
17. Date of most recent peer or quality review:
Page 6 of 11
18. If not within last 3 years, anticipated date of next review:
a. Was the review on-site or off-site? On-site Off-site
b. Was the review modified, qualified, adverse or other? Yes No
If “Yes” to b. above, please provide a copy of the letter of comments, your Firm’s response and committee acceptance
letter.
1. Provide your firm’s recent insurance history below:
Insurance Company
Limits Per
Claim/Aggregate
Policy Period
(Month/Day/Year)
Deductible
Annual Premium
Current Year
Previous Year 1
Previous Year 2
Previous Year 3
Previous Year 4
2. If you are currently insured for professional liability coverage, what is your policy’s retroactive date? (month/date/year)?
____/_____/______ If there is no retroactive date, please check here.
If requesting prior acts coverage you will be asked upon binding coverage to provide a copy of your current insurance
declaration page documenting the expiring retroactive date and limits. Prior acts coverage may not be available if the
date of your current retroactive coverage is different from what we have quoted or if there is any gap between
effective dates.
3. Are you being canceled or non-renewed by your current professional liability carrier? Yes No
If Yes, please explain why:
4. Requested Limits: $100,000/$300,000 $500,000/$500,000 $1,000,000/$1,000,000
$2,000,000/$2,000,000 Other $ /$
Requested Deductible (Per Claim): $5,000 $10,000 $25,000 Other
5. After inquiry with each person as appropriate, in the last five (5) years, has any professional liability Yes No
claim or suit ever been made against the Firm or any predecessor firm or any current or former
member of the Firm or predecessor firm?
If “Yes,” how many? Please complete a separate Supplemental Claim Form
for each claim or suit and include a currently valued loss run for each claim.
INSURANCE AND LOSS HISTORY
Page 7 of 11
6. After inquiry with each person as appropriate, do you, or any of your partners, officers, Yes No
directors, or employees know of any circumstances, acts, errors, omissions, or any allegations
or contentions of any incident that could result in a claim?
If “Yes,” how many? If “Yes,” please complete a separate Supplemental
Claim Form for each potential claim and provide as much details as possible.
7. a. Has the Firm or any member of the Firm ever had his/her certificate, license, or permit to
practice suspended or revoked or voluntarily surrendered due to an investigation? Yes No
b. Has the Firm or any member of the Firm ever been subjected to any disciplinary action by
any State Board of Accountancy, State Society, the AICPA or any other State or Federal
regulators or indicted or convicted of a felony charge? Yes No
c. Is the Firm or any member of the Firm currently under investigation by any of the above
named boards, societies or regulators? Yes No
If “Yes” to a, b, or c, please explain.
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH
CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA,
WISCONSIN, AND WYOMING APPLICANTS: In some states, any person who knowingly, and with intent to defraud any insurance company or other
person, files an application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals
information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: 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 denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
Page 8 of 11
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or other person files an application 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 also be subject to a civil penalty not to exceed $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an
application for insurance or statement of a 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 subjects the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or
omit any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: Date:
Agent/Broker Name:
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Page 9 of 11
PROFESSIONAL
LIABILITY SUPPLEMENTAL CLAIM APPLICATION
This form is to be completed when the Applicant has been involved in any claim or is aware of an incident which
may give rise to a claim. COMPLETE ONE FORM FOR EACH CLAIM OR INCIDENT.
If space is insufficient to answer any questions fully, attach a separate sheet.
In lieu of attaching suit papers, please provide a complete narrative description of the allegations involved
1. Full Name of Applicant:
2. Full Name of Individual(s) or entity involved in the claim:
3. Additional defendants
4. Full Name of Claimant:
5. Indicate whether: CLAIM SUIT Incident/Circumstance Only (no claim or suit)
6. Date and location of alleged act, error or omission:
7. Date of claim: Date reported to Insurance Company:
8. What is the status of the claim? Closed/Settled Open/Pending Incident/Circumstance
9. IF CLOSED:
Total paid including deductible(s)? Responses such as “unknown” or “unavailable” are insufficient.
Defense costs Loss/compensatory damages
Paid by you-out of pocket $ $
Insurance Company $ $
Date Resolved: _____/_____/_____ Trial Out of Court
10. IF PENDING:
(a) Claimant’s settlement demand? $ _____
(b) Insurer’s reserve amounts? Loss $ Defense $
Defendant’s settlement offer (if any): $
(c) Amounts already spent defending the claim? By you? $ By the insurer? $
(d) What is your best estimate of the likely settlement amount for this matter? $
(e) What is your best estimate of the date when you expect this claim to be resolved?
Note: Answering “unknown” or “unavailable” to the above questions is an insufficient response.
11. Name(s) of Insurer(s) responding to this claim or incident
Policy Number:
Limits of Liability: Deductible:
APPLICANT’S INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 10 of 11
12. Provide narrative description of suit, claim or incident, including the allegations involved, the potential size of injury
and your response:
13. Explain what action(s) have been taken to prevent reoccurrence of a similar claim:
______
_____
I declare that the information submitted herein is true to the best of my knowledge and becomes a part of my
Professional Liability Application. I understand that an incorrect or incomplete statement could void my
protection.
Signature of Applicant/Title/Date (Must be signed by a Principal, Partner or Officer of the Firm)
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH
CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA,
WISCONSIN, AND WYOMING APPLICANTS: In some states, any person who knowingly, and with intent to defraud any insurance company or other
person, files an application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals
information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: 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 denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or other person files an application 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 also be subject to a civil penalty not to exceed $5,000 and the stated value
of the claim for each such violation.
Page 11 of 11
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an
application for insurance or statement of a 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 subjects the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or
omit any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: ______________________________________ Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: _____________________________ Date:
Agent/Broker Name:
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Accountants Professional Liability Application

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Completed 2 July 2020

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