Fillable Accountants Renewal Application2 Kinsale Insurance Company

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Accountants Renewal Application2 Kinsale Insurance Company

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Page 1 of 4
ACCOUNTANTS – PROFESSIONAL LIABILITY INSURANCE APPLICATION
RENEWAL APPLICATION
1. Current Kinsale policy number:
2. Legal name of the business who is the primary applicant and will be the first named insured listed on the policy:
3. Please list all other business/dba names for which you are seeking coverage under this policy:
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. Mailing address:
7. 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 past 12 months or are any such changes
contemplated in the next 12 months?
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. Based on the Firm’s fiscal year-end data, provide the following gross revenue figures:
Next Fiscal Year
(Projected)
Last 12 months Revenue
$
$
3. Percentage of revenue from the Firm’s largest clients over the past 12 months (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
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
Describe how Firm maintains independence
4. Approximately what percentage of the Firm’s revenue will be derived from the areas listed below over the next 12
months? (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
• SEC-Section 404
Services
• SEC Work other than
Audit Section 404 Work
or Tax
%
%
%
%
%
%
Yes No
Yes No
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
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%
5. (a) How many suits for the collection of fees have been filed by the firm during the past 12 months?
(b) How many of these suits have been resolved successfully? How many are still open?
Briefly describe any changes or modifications to the firm’s risk management, loss prevention or quality control systems
during the last year including the following:
Use of Engagement Letters Checklists
Partner review system Client screening procedures
Other:
Page 3 of 4
6. Has a peer review been completed within the past 12 months: Yes No
a. Results:
7. If not within last 3 years, anticipated date of next review:
_____________________________________
a. Was the review modified, qualified, adverse or other?__________________
If “Yes” to a. above, please provide a copy of the letter of comments, your Firm’s response and committee acceptance
letter.
1. After inquiry with each person as appropriate, during the last 12 months, have any claims been Yes No
made against the person or entity applying for insurance, or any of your past or present
members, partners, officers, directors, employees, or any predecessors in business, including
any new claims/incidents/circumstances reported to any previous carrier under an extended
reporting period?
If “Yes”, please complete a separate Supplemental Claim form for each claim or suit and include
a currently valued loss run for each claim.
2. Please provide details of any status changes in previously reported claims including changes in
amounts paid in defense costs or to settle claims.
Please include an updated loss run for any previously reported unresolved claims.
3. After inquiry with each person as appropriate, are you, or any of your partners, officers, Yes No
directors, or employees, aware of any circumstances, acts, errors, omissions, or any allegations
or contentions of any incident which may result in a claim?
If “Yes”, please complete a separate Supplemental Claim form for each claim or suit and include
a currently valued loss run for each claim.
4. After inquiry with each person as appropriate, have you, or any of your partners, officers, directors, Yes No
or employees been the subject of any complaint or subject to any disciplinary action by any state
licensing agency or other regulatory body during the last 12 months?
If “Yes”, please provide an explanation of the circumstances and penalty involved. If available,
please provide a copy of the complaint, your response, and a copy of the regulatory body’s decision.
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.
Page 4 of 4
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.
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 Renewal Application2 Kinsale Insurance Company

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Completed 2 July 2020

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