Fillable Audit Service Supplement Application

Fill Online, Printable, Fillable, Blank Audit Service Supplement Application Form

Use Fill to complete blank online KINSALE INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Audit Service Supplement Application

On average this form takes 55 minutes to complete

The Audit Service Supplement Application form is 4 pages long and contains:

  • 1 signature
  • 28 check-boxes
  • 202 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Kinsale Insurance forms online.

BROWSE KINSALE INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 4
1. Pertaining to all audit work performed by the firm, please fill out the following table:
Industry
# of
Clients
(Privately
held)
# of
Clients
(Publicly
held)
# of Clients
Domiciled
Outside the
United
States
How Many
are Fortune
1000
Clients?
Percentage
of Audit
Revenue
# of Clients
with Net
Loss for Last
Fiscal Year
Agribusiness
• Not including Grain
Elevators
%
• Including Grain Elevators
%
Banks/Lending Institutions
%
Broker Dealers %
Colleges & Universities %
Computer/Technology Related %
Construction
%
County Government
%
Employee Benefit/Welfare Plans
•
Defined Benefit Plans %
•
All Other (please explain)
%
Entertainment-Related %
Hospital/Medical
%
Insurance Companies
•
Property Casualty %
•
Life Insurance %
Investment Companies and Funds
•
Hedge Funds and Funds of
Funds
%
•
Other (please explain)
%
Manufacturing %
Mining/Oil & Gas
%
Mortgage Brokers
%
Municipal Government %
Not-for-Profit %
Real Estate
Development/Management
%
Retail %
School Districts %
Service
%
Tribal Entities
%
Unions %
Wholesale/Distribution/Warehousing %
Other: (please explain)
%
TOTAL 100%
AUDIT SERVICE SUPPLEMENTAL APPLICATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
2. In the past five (5) years, has the Firm had any audit client that has declared or filed Yes No
bankruptcy, defaulted on a bond issue, or become insolvent subsequent to service
rendered by the applicant Firm?
If “Yes”, complete the following:
Client Name
#1 #2
Services Provided
Dates Services Provided
Written Opinion Yes No Yes No
Going Concern Reference Yes No Yes No
Date of Default, Bankruptcy or Insolvency
Client’s Revenue
Has the Firm been named in a claim or a
culpable party by the bankruptcy Trustee?
Yes No Yes No
3. In the past 5 years, for any public or private audit engagements, how many audits included significant uncertainties or
contingencies.
Or a going concern statement?
4. Have any of your public clients issued corrected financial statements or has the auditor (your Yes No
firm or the predecessor) withdrawn an audit report or issued a revised audit report?
If “Yes”, identify client and list the year(s) for which the subject financial statements were corrected and/or audit reports
withdrawn or revised, explaining the reason for the statement correction or audit report withdrawal/revision:
5. In the past 3 years, have any of your public clients been the subject of any regulatory inquiry Yes No
or investigation regarding financial statement reporting or disclosure matters?
If “Yes”, identify the client and describe the nature of the inquiry or investigation.
6. Does your Firm have a written policy on audit-related CPE training, including required courses Yes No
and CPE hours per year?
7. Are annually updated engagement letters, signed by clients, used for all Audit Services? Yes No
8. Does a second partner review all audit workpapers and the audit report prior to sign-off Yes No
and release?
If “No”, is a second person review performed by a CPA experienced in audit services? Yes No
9. Does your Firm’s client acceptance procedures pertaining to audit engagements require Yes No
sign-off by a second partner or committee prior to accepting a new engagement?
10. If the Firm received a letter of comment on its last peer review, attach a copy along with the Firm’s response.
Page 3 of 4
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.
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.
Page 4 of 4
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:
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Audit Service Supplement Application

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document