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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 the amounts paid as defense expenses. The retention or deductible may 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.)
Firms not meeting any of the following conditions should contact their agent for the Travelers standard Accountants Professional Liability Application.
Complete this application only if the firm: (1) has gross annual revenue of $500,000 or less, and (2) does not render Audit, Business Valuation, Forecast, Projection, Limited Partnership or Tax Shelter Syndication, Merger and Acquisition, Securities, or Trustee services.
For a Pass with Deficiencies or a Fail result, attach a copy of the report and details of corrective action.
*Defense expenses within limits means the limits of liability are eroded by both damages and defense expenses.
Defense expenses outside limits means the limits of liability are eroded by damages only.
Premiums above do not include applicable taxes or surcharges. Refer to the insurance quotation for any additional state-specific charges.
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.
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 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 a settlement or award payable from insurance proceeds shall 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 for the purpose of defrauding 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.
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; Travelers may accordingly modify or withdraw any outstanding quotation.
* If you are electronically submitting this document, apply your electronic signature to this form by checking the Electronic Signature and Acceptance box below. By doing so, you agree that your use of a key pad, mouse, or other device to check the Electronic Signature and Acceptance box constitutes your signature, acceptance, and agreement as if actually signed by you in writing and has the same force and effect as a signature affixed by hand.
For a yes response to question 6, complete the following chart for each predecessor firm. For the purposes of this application, predecessor firm means any accounting firm that is dissolved or inactive and is no longer rendering professional services and: 1) at least 50% of the principals, owners, officers, or partners of such firm have joined the firm or another predecessor firm, or 2) some or all of such firm's principals, owners, officers, or partners have joined and more than 50% of such firm's assets have been assigned or transferred to the firm.
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