Under $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 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.

General Information

Entity Type*

APPLICANT INFORMATION

1. Indicate the number of firm members (including owners, officers, and partners) who fall within each category below
   Full time professional

   Part time professional

   Non-professional
2. List any professional designations or memberships in professional organizations for all firm members*
   
3. What is the firm’s anticipated 12 month revenue for the current fiscal year? (Combine total actual revenue to date and estimated revenue until the end of the fiscal year)*
   
4. What was the firm’s actual 12 month revenue for the prior fiscal year?*
   
5. 1. Indicate the total number of clients in the past year*
      
   2. Does any client represent 25% or more of the firm’s gross annual revenue?*
      YesNo
      If yes, provide details in the Additional Information section at the end of this application
6. Does the firm have any predecessor firms?*
   YesNo
   A description of predecessor firms and space to provide details for yes answers is in the Additional Information section at the end of this application
7. 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%.
   Reminder: This application cannot be used by firms rendering any Audit, Business Valuation, Forecast and Projection, Limited Partnership or Tax Shelter Syndication, Merger and Acquisition, Securities, or Trustee services.
   Area of Practice

   Percentage of Revenue

   Engagement Letters Used?
   Bookkeeping/Write-ups/Payroll*

   %

   YesNo
   Reviews*

   %

   YesNo
   Compilations*

   %

   YesNo
   Personal Financial Planning or Investment Advisory Services (complete Investment Advice/ Financial Planning supplement)*

   %

   YesNo
   Tax - Individual*

   %

   YesNo
   Tax - Business*

   %

   YesNo
   Tax - Estate and Trust*

   %

   YesNo
   Forensic Accounting/Litigation Support/Investigative Accounting*

   %

   YesNo
   Management Advisory Services*

   %

   YesNo
   Hardware/Software Consulting and Sales*

   %

   YesNo
   Other (describe in detail)

   %

   YesNo
   Total

   100%
8. Do any members of the firm provide services in the name of, serve as a director or officer for, or have a combined ownership interest greater than 10% in, any entity other than the firm?*
   YesNo
   If yes, is that entity a client?
   YesNo
   For any yes answers above, provide complete details in the Additional Information section at the end of this application. Note: additional supplemental applications may be required.
9. Are any members of the firm engaged in any non-accounting services (including services as an attorney, insurance agent, or registered representative) on behalf of the firm?*
   YesNo
   If yes, provide details in the Additional Information section at the end of this application
10. Check all loss prevention and risk management controls below that are in place in the firm
    1. Control systems / conflict of interest procedures
       Are automated
       Prohibit engagements potentially adverse to any current or former client
       Have redundancies in input, review, and oversight procedures
       Track tax, filing, and all other critical deadline
    2. Client intake and screening procedures
       Examine the complexity of the proposed services, experience/ability to represent, and likelihood of success.
       Firm   doesdoes not sue to collect professional fees.
       If suits for fees are indicated, describe all collection suits in the past two years on a separate sheet. 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 management includes
       Formal office policies and procedures
       A formal risk control or loss prevention program
       No accounts receivable greater than 90 days past due
    4. Engagement letters
       Are used for all matters, including revised engagements for existing clients
       Explain all issues, including matters undertaken, not undertaken, risks, and billing
       Contain an alternative dispute resolution provision or otherwise seek to limit liability
11. 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:

    FailPassPass with deficiency

    For a Pass with Deficiencies or a Fail result, attach a copy of the report and details of corrective action.

12. Has any member of the firm ever: 1) had their license suspended, revoked, or been subject to any kind of investigation or disciplinary action by any entity providing regulatory or professional oversight, or 2) been indicted for, 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 services or business activities?*
    YesNo
    If yes, provide full details in the Additional Information section at the end of this application.
13. 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.
14. 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.
15. Does the firm currently carry professional liability insurance?*
    YesNo
    If yes, complete the following section
    Carrier

    Policy Period Start Date

    Policy Period End Date
    Limits$

    Deductible$

    Premium

    Retroactive Date
16. Has any person or entity seeking coverage under this proposed policy ever had their professional liability insurance nonrenewed 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

PICK A PREMIUM PLAN

*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.

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 WARNINGS

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.

SIGNATURE AND AUTHORIZATION

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.

Other additional information