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Accounting Firms
Application
General Information
Name of Applicant
Address
City
State
Zip
Phone
Fax
Email
Insured Contact Person
Staff Size
Professional
Clerical
Next Step
Area of Practice Percentages (percentage must total 100%)
Tax
Management Advisory Services
PFP/Investment Advisory Service
Information Technology
Bookkeeping/Compilation
General Business Planning
Review
Litigation Consulting
Audit of Non-public Clients
Other Assurance Service
Gross Annual Revenues
Last Fiscal Year
Estimated Current Fiscal Year
Does your firm use engagement letters?
Select
Yes
No
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Within the past 3 years, has your firm undergone a peer, quality or voluntary tax practice review in the sponsorship of the AICPA, a state CPA society or other professional organization?
If "YES", opinion rendered:
N/A
Unqualified
Modified
Other
Other
Has a member of your firm attended a Professional Liability Insurance Program Risk Management Seminar in the last 3 years?
Select
Yes
No
If "Yes", most recent attendance:
Is at least one member of your firm an active member of one of the following professional associations?
AICPA
State CPA Society
Other
Other
Does the firm belong to the PCPS section of the AICPA?
Select
Yes
No
Is at least one member of your firm an active member of one of the following professional associations?
Employee Benefit Plan Audit Center
Government Audit Quality Center
Has your firm been claim free for the past five (5) years?
Select
Yes
No
If "No", please provide a brief description of the loss and amount paid
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Current Policy
Does your firm currently carry Accountants Professional Liability insurance?
Select
Yes
No
Limit
Select
$500,000
$1,000,000
$2,000,000
Other
Other
Deductible
Select
$1,000
$5,000
$10,000
Other
Other
Policy Expiration Date
Prior Acts Date / Retroactive Date
Premium Amount
Does you firm carry Employment Practices Liability coverage?
Select
Yes
No
Current Carrier
Effective Date
Limits
Deductible
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