Over $100k New Business Application

The information requested in this Application is for a Claims-Made policy. If issued, the policy will apply only to claims first made during the policy period, or any applicable extended reporting period.

The limit of liability available to pay losses will be reduced and may be exhausted by amounts paid as defense expenses. The deductible will apply to defense expenses. (For policies issued in New York, the limit of liability may be reduced up to 50% for amounts paid as defense expenses, and the deductible may apply to up to 50% of defense expenses).

Answer each question on behalf of all entities seeking insurance coverage, unless specifically requested otherwise.

General Information

Primary Office Address*

Mailing Address (if different)

Web Address

Email Address (for the delivery of risk management materials)*

Entity Type*

If coverage is desired under this proposed policy for any entities, other than the firm listed above, that provide accounting services, complete the Separate Entity Supplement.

Firm Information

1. List number of firm staff as follows (include employees who work 500 or more hours per year)

   CPAs

   Non-CPAs
   Owners, Partners, Shareholders
   All Other Accounting or Tax Professionals
   Other Consulting Professionals (not included above)
   Administrative
   Total
2. What is the firm’s anticipated 12 month revenue for the current fiscal year? (Combine the actual revenue to date and estimated revenue until the end of the fiscal year).*

   $

3. What was the firm’s actual 12 month revenue for the prior fiscal year?*
   $
4. Have there been in the past 12 months, or are there anticipated in the next 12 months, any material changes to the firm including mergers, acquisitions, restructuring, or the addition of a new client industry or change to the scope of practice?*
   YesNo

   If yes, please explain
   

5. For all services provided, indicate the approximate percentage of the firm’s prior fiscal year 12 month revenue and whether engagement letters are used for each practice area. The total percentage must add up to 100%.*
   Area of Practice

   % of Revenue

   Engagement letters on all matters?

   Bookkeeping

   Bookkeeping/Write-ups/Payroll*

   %

   YesNo

   Tax

   Individual Tax*

   %

   YesNo
   Business Tax*

   %

   YesNo
   Estate and Trust Tax*

   %

   YesNo

   Attestation

   Private Entity Audit⁽¹⁾*

   %

   YesNo
   Publicly Traded Entity Audit⁽¹⁾*

   %

   YesNo
   Non-Financial Statement Audit⁽¹⁾*

   %

   YesNo
   Reviews*

   %

   YesNo
   Compilations*

   %

   YesNo

   Consulting

   Business Valuations*

   %

   YesNo
   Forecasts and Projections*

   %

   YesNo
   Forensic Accounting/Litigation Support/Investigative Accounting*

   %

   YesNo
   Hardware/Software Consulting and Sales*

   %

   YesNo
   Management Advisory Services*

   %

   YesNo
   Mergers and Acquisitions*

   %

   YesNo
   Personal Financial Planning or Investment Advisory Services⁽²⁾*

   %

   YesNo

   Specialty Services

   Executor/Administrator/Trustee⁽³⁾*

   %

   YesNo
   Limited Partnership & Tax Shelter Syndication⁽⁴⁾*

   %

   YesNo
   Securities⁽⁴⁾*

   %

   YesNo
   Registered Representative

   Quote for Coverage?

   YesNo

   %

   YesNo
   Life and Health Insurance Agent

   Quote for Coverage?

   YesNo

   %

   YesNo

   Other Services

   (describe):

   %

   YesNo
   Total

   100%
   Complete: (1) Audit Services Supplement (2) Personal Financial Planning and Investment Advice Supplement (3) Executor, Administrator, and Trustee Supplement (4) Securities Supplement

6. Does any member of the firm provide professional services as a practicing lawyer, real estate agent or broker, registered investment adviser, or securities agent or broker?*
   YesNo

   If yes, please complete the following chart:

   Employee Name

   Type of License

   Types of Services Provided

   Professional Liability Insurer

   Limits of Liability
   Is separate Professional Liability Insurance in place?YesNo

   ---

   Employee Name

   Type of License

   Types of Services Provided

   Professional Liability Insurer

   Limits of Liability
   Is separate Professional Liability Insurance in place?YesNo
7. 1. Indicate the total number of clients for the past 2 years:
      Last year*

      Year Prior*
   2. Does any client represent 25% or more of the firm’s gross annual revenue?*
      YesNo

      If yes, provide details below. Use the Additional Information section at the end of the application if needed.

      Client Industry

      Services Provided

      Percent of Firm Revenue

      No. of Years as a Client
      %
8. Within the past 5 years has the firm provided services to any client while a member of the firm, or their spouse, served as a director or officer of the client, or had a combined ownership interest greater than 10% in the client?*
   YesNo
   If yes, complete the Outside Interest Supplement.
9. Within the past 5 years, excluding activities as a trustee or receiver, has any client been the subject of bankruptcy, insolvency, or any bankruptcy, or, if a financial institution, operated under regulatory direction or agreement?*
   YesNo
   If yes, complete the Insolvency Supplement.
10. Within the past 5 years, has the firm or any member of the firm:
    1. organized, arranged, procured, or evaluated investments or real estate tax shelters, or prepared projections for use in these areas?*
       YesNo
    2. participated in the management of any investment partnership, limited partnership, tax shelter, or other investment venture?*
       YesNo
       If yes to any part of a. or b., provide details:
11. Within the past 5 years, has the firm or any member of the firm:
    1. received commissions, fees, reciprocity, or revenue for the referral, sale, or promotion of investments or tax shelters?*
       YesNo
    2. made recommendations as to the sale or purchase of any investments, including specific stocks, bonds, or other securities, for which you received compensation?*
       YesNo
    3. invested, received, disbursed, or in any way acted in a decision-making capacity, with respect to a client’s funds?*
       YesNo
       If yes to a., b., or c. complete the Personal Financial Planning and Investment Advice Supplement.

LOSS PREVENTION/RISK MANAGEMENT

12. Check all loss prevention and risk management controls below that are in place at the firm
    1. Control systems and conflict of interest procedures:
       Are automated.
       Prohibit engagements potentially adverse to any current or former client.
       Prohibit engagements where any professional has a financial interest, including a loan, in the proposed client or subject matter.
       Have redundancies in input, review, and oversight procedures.
       Track tax, filing, and all other critical deadlines.
    2. Client screening procedures and suits for fees:
       Screening procedures examine the complexity of the proposed services, experience and ability to represent the client, and likelihood of success.
       Screening procedures examine the client’s financial condition, credit rating or bill paying history, number of previous accounting firms employed, and reasonableness of expectations.
       Firm does not sue to collect professional fees. If the firm has sued for fees, describe all collection suits in the past two years in the Additional Information section at the end of this application. Include services rendered, dates of service, date of suit, fee amounts, status or outcome, and whether the firm is still providing services to this client.
    3. Firm loss prevention procedures include:
       Formal office policies and procedures.
       A formal risk control or loss prevention program.
       A member of the firm dedicated to overseeing client billing and reviewing all outstanding accounts.
       An administrator or executive dedicated exclusively to firm management issues.
       An executive committee with authority to overrule even the most senior members.
    4. Engagement letters:
       Are used for all matters, including updated letters for new matters for existing clients.
       Explain all issues, including matters undertaken, not undertaken, risks involved, and billing procedures.
       Contain an alternative dispute resolution, limitation of liability, or indemnification provision.
    5. Firm oversight includes:
       Regular review by firm management of the status of all engagements.
       Required updates to firm management on any problem files or engagements.
       Procedures to remove professionals from problem matters and reassign or withdraw from the engagement.
       Required attendance by all firm members at regular meetings communicating matters of common importance.
       Internal review of all significant GAAP and GAAS opinions and decisions.
13. Is the firm subject to Peer Review?
    YesNo

    If yes, is the firm in compliance with all peer review requirements?
    YesNo

    Date of most recent review:
    
    Review Result:

    Pass

    Pass with deficiencies

    Fail

    Attach a copy of the Peer Review and details of any corrective action.

CLAIMS AND PRIOR INSURANCE

14. Has any member of the firm ever:
    1. had their license suspended, revoked, or been subject to any investigation or disciplinary action by any entity providing regulatory or professional oversight?*
       YesNo
    2. been indicted or convicted of a felony or paid any criminal or civil penalty or fine, including a tax preparer’s fine, in connection with any professional service or business activity?*
       YesNo
       If yes to a. or b., provide full details in the Additional Information section at the end of this application.
15. Has any claim involving professional services been made against the firm, any predecessor firm, or any current or former partner, officer, shareholder, or employee in the past 5 years or earlier if the claim is still pending?*
    YesNo
    If yes, complete the Claim, Suit, or Incident Supplement for each claim.
16. Does any person seeking coverage under this proposed policy have knowledge of any incident, act, error, or omission involving professional services that could reasonably be expected to be the basis of a claim?*
    YesNo
    If yes, complete the Claim, Suit, or Incident Supplement for each claim or incident.
17. Does the firm currently carry professional liability insurance?*
    YesNo
    If yes, complete the following section or provide copies of the current declarations page:
    Carrier

    Policy Period Start Date

    Policy Period End Date
    Limits$

    Deductible$

    Premium$

    Retroactive Date

    ---

     
    Carrier

    Policy Period Start Date

    Policy Period End Date
    Limits$

    Deductible$

    Premium$

    Retroactive Date
18. Has any person or entity seeking coverage under this proposed policy ever had their professional liability insurance non-renewed or cancelled? (Missouri applicants: do not respond)
    YesNo
    If yes, provide details in the Additional Information section at the end of this application.

LIMITS AND DEDUCTIBLES

Limit Type:

Deductible Type:

NOTICE REGARDING COMPENSATION

For information about how Travelers compensates independent agents, brokers, or other insurance producers, please visit this website: http://www.travelers.com/w3c/legal/Producer_Compensation_Disclosure.html

If you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at Travelers, Agency Compensation, One Tower Square, Hartford, CT 06183.

FRAUD STATEMENTS – ATTENTION APPLICANTS IN THE FOLLOWING JURISDICTIONS

ALABAMA, ARKANSAS, DISTRICT OF COLUMBIA, MARYLAND, NEW MEXICO, AND RHODE ISLAND: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company to defraud or attempt 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 to defraud or attempt to defraud the policyholder or claimant regarding a settlement or award payable from insurance proceeds will be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

FLORIDA: 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.

KENTUCKY, NEW JERSEY, NEW YORK, OHIO, AND PENNSYLVANIA: 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. (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation.)

LOUISIANA, MAINE, TENNESSEE, VIRGINIA, AND WASHINGTON: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company to defraud the company. Penalties include imprisonment, fines, and denial of insurance benefits.

OREGON: 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 may be guilty of a crime and may be subject to fines and confinement in prison.

PUERTO RICO: Any person who knowingly and intending to defraud presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, will incur a felony and, upon conviction, will be sanctioned for each violation with the penalty of a fine of not less than $5,000 and not over $10,000, or a fixed term of imprisonment for three years, or both penalties. Should aggravating circumstances be present, the penalty established may be increased to a maximum of five years; if extenuating circumstances are present, it may be reduced to a minimum of two years.

SIGNATURES

The undersigned Authorized Representative represents that to the best of his or her knowledge and belief, and after reasonable inquiry, the statements provided in response to this Application are true and complete, and may be relied upon by Travelers as the basis for providing insurance. The Applicant will notify Travelers of any material changes to the information provided.

*If electronically submitting this document, electronically sign this form by checking the Electronic Signature and Acceptance box below. By doing so, the applicant agrees that use of a key pad, mouse, or other device to check the Electronic Signature and Acceptance box constitutes acceptance and agreement as if signed in writing and has the same force and effect as a signature affixed by hand.

Electronic Signature and Acceptance – Authorized Representative

Additional Information