Fillable Miscellaneous Professional Liability APPLICATION Accountants/Financial Advisors or Investment (Risk Placement Services, Inc.)

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Miscellaneous Professional Liability APPLICATION Accountants/Financial Advisors or Investment (Risk Placement Services, Inc.)

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MP 7004a 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 1 of 7
Miscellaneous Professional Liability
APPLICATION – Accountants/Financial Advisors or
Investment Managers
THIS APPLICATION IS FOR A COVERAGE PART WRITTEN ON A CLAIMS-MADE BASIS.
"CLAIMS" MUST BE FIRST MADE AGAINST ANY INSURED DURING THE "POLICY
PERIOD" OR ANY APPLICABLE EXTENDED REPORTING PERIOD, AND REPORTED TO
US AS SOON AS PRACTICABLE DURING THE "POLICY PERIOD", ANY SUBSEQUENT
RENEWAL OF THE POLICY OR ANY APPLICABLE EXTENDED REPORTING PERIOD. THE
INSURANCE FOR WHICH THIS APPLICATION IS MADE APPLIES ONLY IF THE "WRONGFUL
ACT" OUT OF WHICH THE "CLAIM" AROSE OCCURRED ON OR AFTER THE RETROACTIVE
DATE, IF ANY, SHOWN IN THE DECLARATIONS AND BEFORE THE END OF THE "POLICY
PERIOD". "DEFENSE EXPENSES" ARE PAYABLE WITHIN, NOT IN ADDITION TO, THE LIMIT OF
LIABILITY.
INSTRUCTIONS: Please complete the entire form. If there is insufficient space to complete an answer, please continue
on a separate sheet indicating the question number. If a section does not apply or is not relevant, answer “N/A” or “none”.
Information provided by you will be used by underwriters in determining the acceptability of adding the professionals to
the Miscellaneous Professional insurance coverage.
1. Applicant/Organization Name_____________________________________________________________________
2. Address of Organization_________________________________________________________________________
3. Address where specified professional(s) is located____________________________________________________
4. Please provide the number of professionals seeking coverage: # of Accountants _______________
# of Financial Advisors ___________
5. Type of entity:
Non Profit For Profit Other, Please describe:_____________________________________
6. What is the professionals working relationship with the Applicant/Organization?
Employee Volunteer Contractor
7. Are the Professionals requesting coverage:
Full Time Part time If Part Time, How many Hours per week do
they work on behalf of the Organization? __________ How many weeks per year? __________
8. List the responsibilities/duties performed for the Organization (please be specific).
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Accountants:
1. Do you or will you perform any of the following services on behalf of the Organization?
Organization Internal Business Services for Others
Audit Services Yes No Yes No
Tax Services
Yes No Yes No
Bookkeeping Services
Yes No Yes No
Compilations and Reviews
Yes No Yes No
Data Processing services
Yes No Yes No
Pension & Benefit plans
Yes No Yes No
MP 7004a 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 2 of 7
Estate Planning Yes No Yes No
Fiduciary Activities
Yes No Yes No
Business valuation
Yes No Yes No
Management Consulting
Yes No Yes No
Other(please describe:_______________________________________________________________________
2. Do you provide any other professional services on behalf of the Organization?
Yes No
If yes, please describe below:
____________________________________________________________________________________________
____________________________________________________________________________________________
3. Do you provide services as a Lawyer, Insurance Agent/Broker, Escrow Agent, or Investment/Financial Advisor.
Yes No If yes, provide particulars of services:___________________________________________________
____________________________________________________________________________________________
4. Have all CPA’s seeking coverage completed continuing education required for their level of license and/or
certificate?
Yes No If no, indicate exceptions:__________________________________________________
___________________________________________________________________________________________
5. Does the organization delegate work to or subcontract work from other accounting firms?
Yes No
If yes, indicate nature of work.___________________________________________________________________
6. What are the total gross fees to the organization associated with providing accounting services to members, clients,
or other third parties?__________________________________________________________________________
7. Provide information on the largest entities (members, clients, or other third parties) for which services are provided.
(any accounting for over 10% of the total services or else the largest three)_______________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
8. If fees are specifically charged for accountant services, has the firm adopted a policy of not filing suit for fees?
Yes No If no, indicate suits for collection of fees in the last five years._______________________________
___________________________________________________________________________________________
9. Have the accountants performed any professional services for any publicly traded company?
Yes No
If yes, describe nature of services and company.____________________________________________________
___________________________________________________________________________________________
10. Do you utilize engagement letters which specifically outline the nature and scope of the work to be performed for the
organization?
Yes No
11. Do you audit or review investment funds? Yes No. If yes, please provide fund names and asset values:
____________________________________________________________________________________________
____________________________________________________________________________________________
12. Do you or the organization audit or perform valuations of investments or investment funds for which you or the
organization are the financial or investment advisor?
Yes No if yes, please indicate which funds or
investements.________________________________________________________________________________
13. Are financial statements, reports and projections that are prepared by you or your staff checked by an owner,
principal, partner or manager prior to their release?
Yes No
14. Are business tax returns checked and verified by a disassociated preparer prior to their release?
Yes No
15. With regard to unaudited statements, do you always issue a disclaimer of opinion in or with such statements?
Yes No
16. Does the professional applicant;
a. Invest Organization’s funds or act in a decision making capacity with respect to the Organization?
Yes No
If yes, please describe: _____________________________________________________________________
b. Control receipt or disbursement of any part of Organization’s funds?
Yes No
c. Required to be Bonded for handling Organization’s funds?
Yes No
MP 7004a 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 3 of 7
17. Have the accountants or organization had any quality peer review of accounting and review services? Yes No
If yes, indicate when, who performed peer review and the outcome._______________________________________
____________________________________________________________________________________________
18. Have all known potential claims, incidents or suits, if any, been reported to your present carrier? Yes No
19. Has the applicant, predecessors or any other person for whom insurance is being requested ever been subject to
disciplinary action or reprimand by any state board of accountancy (or equivalent thereof), the S.E.C. , any other
governmental regulatory agency, federal , state, local court, or any state or national accounting society?
Yes No If yes, please provide full details:__________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
20. Is the professional applicant controlled, owned or associated with any other firm, corporation or company, other than
as stated above?
Yes No If yes, please provide full details:____________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
21. Have you ever been convicted of a crime or felony? Yes___ No___
22. Provide information on your in-force professional Liability insurance. (if none exists, please indicate “none”)
a. Insurance Company Name ________________________________Expiration date _________________
b. Limits of Liability $______________________________________Policy # ______________________
c. Does your policy cover you while performing work for the agency/organization? Yes___ No___
d. Retroactive Date _______________________________________
Financial Advisor/Investment Manager:
1. What are the professional qualifications of the Financial Advisor(s) applying for coverage?
Licenses Held:_________________________ Professional Organizations:_____________________________
Length of time working as an Advisor :______________________________________________
Length of time working with the Organization:_________________________________________
2. Is the professional applicant registered with the SEC as an investment advisor?
Yes No
If yes, please provide full details:______________________________________________________________
_________________________________________________________________________________________
3. Is the applicant registered with any other regulatory agency, commission or association?
Yes No
If yes, please provide full details:______________________________________________________________
_________________________________________________________________________________________
4. Does the professional applicant contract with any Outside Service Providers?
Yes No
If yes, please provide full details:______________________________________________________________
_________________________________________________________________________________________
5. Do you manage investment funds or advise the strategy for the management of investment funds?
Yes No
If yes, please attach a separate page providing names of funds and fund asset sizes managed.
6. Please provide on a separate page a list of your three(3) largest clients and any involving over 10% of your total
services.
7. Are the investment and management fees charged fully disclosed to investment participants at least annually?
Yes No If No please explain.____________________________________________________________
________________________________________________________________________________________
8. Do you provide an investment strategy document as part of the client disclosure statement indicating the portfolio
mix planned for the client, the relative risk levels of the investment types and obtain client signoff?
Yes No
If No please explain._________________________________________________________________________
9. For marketable investments, do clients receive monthly statements showing the current market valuation of
investments?
Yes No If No please explain.__________________________________________________
MP 7004a 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 4 of 7
_________________________________________________________________________________________
10. For investments that do not have an active market, indicate types of asset value information provided, sources of
such information, and frequency information is provided. ____________________________________________
_________________________________________________________________________________________
11. Do you or the organization audit or perform valuations of investments or investment funds for which you or the
organization also are the financial or investment advisor?
Yes No
If yes, indicate which funds or investments:_______________________________________________________
12. Does the professional applicant provide any computer service and/or internet service for its clients or the general
public?
Yes No If yes, please describe services provided and for whom:__________________________
_________________________________________________________________________________________
13. Is the applicant proposed for this insurance engaged in any business other than as a financial advisor?
Yes No If yes, please provide full details:___________________________________________________
_________________________________________________________________________________________
14. Does the applicant manage private account assets of related and/or affiliated companies? Yes No
If yes, please provide full details:______________________________________________________________
_________________________________________________________________________________________
15. Does the advisor recommend or invest in any f the following specialty investments on behalf of the organization?
Below investment grade bonds(BBB or lower)
Yes No
Guaranteed investment contracts
Yes No
Commodity or other futures
Yes No
Precious metals
Yes No
Mortgage, Mortgage pools, or other Mortgage backed securities
Yes No
Real Estate Investment Trusts (REITS)
Yes No
Option contracts or futures
Yes No
General or Limited Partnerships
Yes No
Real Estate
Yes No
Foreign or International Securities
Yes No
Derivatives
Yes No
Other(please describe:___________________________________________
16. With respect to the above specialty investments, does applicant require a signed disclosure statement
acknowledging the volatility of such investments from organization and/or clients?
Yes No
If no, please explain:________________________________________________________________________
_________________________________________________________________________________________
17. Does the applicant have written formal procedures to ensure the clients investment management contracts are
adhered to?
Yes No
18. Are annual independent audits performed for all investment funds and for individual account records?
Yes No
If no please explain.__________________________________________________________________________
19. Has the applicant been fined by the SEC or any other regulatory authority for any reason?
Yes No
If yes, please provide full details:______________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
20. Has any person(s) or entity(s) proposed for this insurance ever been a party to or subject of any civil, criminal,
disciplinary action or administrative proceeding alleging or investigating a violation of any federal or state security
law or regulation?
Yes No If yes, please provide full details:___________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
21. Have you ever been convicted of a crime or felony? Yes___ No___
22. Provide information on your in-force professional Liability insurance. (if none exists, please indicate “none”)
MP 7004a 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 5 of 7
a. Insurance Company Name ________________________________Expiration date _________________
b. Limits of Liability $______________________________________Policy # ______________________
c. Does your policy cover you while performing work for the agency/organization? Yes___ No___
d. Retroactive Date _______________________________________
NOTICE TO APPLICANT – PLEASE READ CAREFULLY
FOR THE PURPOSE OF THIS APPLICATION, THE UNDERSIGNED, AS AUTHORIZED AGENT FOR ALL
PERSONS AND ENTITIES PROPOSED FOR THIS INSURANCE, DECLARES THAT TO THE BEST OF
HIS/HER KNOWLEDGE THE STATEMENTS HEREIN ARE TRUE AND COMPLETE. THE INSURER IS
AUTHORIZED TO MAKE ANY INQUIRY IN CONNECTION WITH THIS APPLICATION. SIGNING THIS
APPLICATION DOES NOT BIND THE INSURER TO ISSUE, OR THE APPLICANT TO PURCHASE, ANY
INSURANCE POLICY.
THE INFORMATION CONTAINED IN AND SUBMITTED WITH THIS APPLICATION IS ON FILE WITH THE
INSURER. IF THE INFORMATION IN THIS APPLICATION MATERIALLY CHANGES PRIOR TO THE
EFFECTIVE DATE OF THE POLICY, THE APPLICANT MUST NOTIFY THE INSURER, WHO MAY MODIFY
OR WITHDRAW THE QUOTATION.
THE UNDERSIGNED DECLARES THAT THE INDIVIDUALS AND ORGANIZATIONS PROPOSED FOR THIS
INSUR
A
NCE HAVE BEEN NOTIFIED THAT:
A. THIS POLICY APPLIES ONLY TO "CLAIMS" FIRST MADE OR DEEMED MADE AGAINST THE
INSUREDS DURING THE "POLICY PERIOD" OR EXTENDED REPORTING PERIOD, IF EXERCISED;
A
ND
B. THE LIMIT OF LIABILITY IS REDUCED BY AMOUNTS INCURRED AS "DEFENSE EXPENSES" AND
SUCH EXPENSES WILL BE SUBJECT TO THE DEDUCTIBLE AMOUNT.
(WORDS WITHIN QUOTATION MARKS ARE DEFINED IN THE INSURANCE POLICY.)
FRAUD STATEMENT
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.
FRAUD STATEMENT TO ALABAMA APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly presents false information in an application for insurance is guilty of a crime and may be subject
to restitution fines or confinement in prison, or any combination thereof.
FRAUD STATEMENT TO ARKANSAS 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.
FRAUD STATEMENT 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
policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or
claimant with regard to settlement or award payable from insurance proceeds shall be reported to the
Colorado division of insurance within the department of regulatory agencies.
FRAUD STATEMENT 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.
MP 7004a 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 6 of 7
FRAUD STATEMENT TO FLORIDA APPLICANTS
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 of the
third degree.
FRAUD STATEMENT 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.
FRAUD STATEMENT 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.
FRAUD STATEMENT 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 a denial of insurance
benefits.
FRAUD STATEMENT TO MARYLAND APPLICANTS
Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit
or who knowingly and willfully presents false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison.
FRAUD STATEMENT 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.
FRAUD STATEMENT 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.
FRAUD STATEMENT TO NEW YORK APPLICANTS
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 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 five thousand dollars and the
stated value of the claim for each such violation.
FRAUD STATEMENT TO OHIO APPLICANTS
Any person who, with intent to defraud or knowing that he 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.
FRAUD STATEMENT TO OKLAHOMA APPLICANTS
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes
any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information
is guilty of a felony.
FRAUD STATEMENT TO OREGON APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents materially false information in an application for insurance may be guilty of a crime and
may be subject to fines and confinement in prison.
MP 7004a 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 7 of 7
FRAUD STATEMENT 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 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 such person to criminal and civil penalties.
FRAUD STATEMENT TO RHODE ISLAND 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, including failing to disclose whether
the applicant or applicants have been convicted of any degree of the crime of arson, is guilty of a crime and
may be subject to fines and confinement in prison.
FRAUD STATEMENT 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.
FRAUD STATEMENT TO VERMONT APPLICANTS
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 conceals for
the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance
act, which may be a crime and subjects such person to criminal and civil penalties.
FRAUD STATEMENT 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.
FRAUD STATEMENT TO WASHINGTON 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.
FRAUD STATEMENT TO WEST VIRGINIA 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.
______________________________________________ _______/_______/_______
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Miscellaneous Professional Liability APPLICATION AccountantsFinancial Advisors or Investment (Risk Placement Services, Inc.)

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Completed 23 November 2020

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