Firm Name
Contact Name
Street Address
Zip City County State
E-mail Website
Date Established Phone # Fax #
Total # of Professionals (Includes CPA’s, Public Accountants, Tax Preparers, Consultants, Enrolled Agents and Bookkeepers)
IF YOU ARE A NEW ACCOUNT:
Desired Effective Date Retroactive Date
IF YOU ARE A RENEWAL ACCOUNT:
Expiring Policy #

ELIGIBILITY: To be eligible for this application, Questions 1 through 11 must all be answered “Yes”. If you are not eligible, please call our office at (781) 581-2500 or visit our website www.FirstIndemnity.net for the full Accountants Program Application.

1.	The applicant firm’s total gross revenue did not exceed $500,000 in the last fiscal year: Yes No
2.	A member of my firm is a licensed CPA, Tax Preparer, Bookkeeper or other type of Accounting Professional: Yes No
3.	My firm’s professional staff is 5 or fewer: Yes No
4.	Firm owners or employers do not receive commissions for the referral, solicitation for sale, or sale of securities, insurance products or investments: Yes No
5.	No member or employee of the applicant firm has discretionary authority to invest or control client funds Yes No
6.	Audit engagements generate 55% or less of the firm’s gross billings, and the firm has not performed any public audit/attest work in the last five years: Yes No
7.	Management Advisory Services generate 55% or less of the firm’s gross billings: Yes No
8.	Firm owners or employees do NOT have discretionary authority to invest client funds: Yes No
9.	My firm does NOT provide assurances as to the care received by an individual, or consult with clients on care options, or provide assistance with daily activities (ElderCare): Yes No
10.	My firm has NOT audited any publicly held clients in the past five years: Yes No
11.	My firm has NOT prepared financial statements that have been used in any Securities Offerings whether public, private, registered or unregistered: Yes No

CLAIM EXPERIENCE: If you respond “Yes” to any of the statements below, complete the corresponding Claim, Disciplinary and/or Fee Suit Supplemental Applications and include them with this application.

1.	After inquiry of all owners, partners, officers and professionals of the firm and firm affiliates, within the past five years have any past or present personnel:
	a.	Been the subject of any regulatory or disciplinary investigation or inquiry (both formal and informal) or suspended from practice Yes No
	b.	Charged or plead guilty to, or indicted on a criminal charge? Yes No
	c.	Become aware of any professional liability claims made against the firm, firm affiliates, their personnel, or their firm’s predecessors in business? Yes No
	d.	Become aware of any act, omission or fee dispute which might be expected to be the basis of a claim or suit against the firm, firm affiliates, their personnel or the firm’s predecessor firm in business? Yes No

Your Practice Information

Staff size

Number of Professionals:

Number of Clericals:

Gross Annual Revenues:

Last Fiscal Year:

Estimated current fiscal year:

Areas of Practice: MUST EQUAL 100%

Review:

Information Technology

Audit of Non-public Clients:

Other Assurance Services:

Tax:

PFP/Investment Advisory Services:

Bookkeeping/Compilation:

Management Advisory Services:

General Business Planning:

Litigation Consulting:

Total

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Does your firm use engagement letters on the majority of engagements.

Yes No

Within the past 3 years, has your firm undergone a peer, quality or voluntary tax practice review under the sponsorship of the AICPA, a state CPA society or other professional organization?

Yes No

If "Yes", Opinion rendered:

Unqualified

Modified

Other

Has a member of your firm attended an AICPA Professional Liability Insurance Program Risk Management Seminar in the last three years.

Yes No

If “Yes”, most recent attendance date?

Is at least one member of your firm an active member of one of the following professional associations?

AICPA

State CPA Society

Other

Has your firm been claim free for the past five years?

Yes No

Does your firm currently carry accountant’s professional liability insurance?

Yes No

(Complete the grid below if “Yes”)

Current Carrier	Expiration Date	Limits	Deductible	Prior Acts / Retroactive Date	Policy Premium
					$

If you are new business, please attach a copy of your current policy’s declarations page to confirm your retroactive date

Desired Coverage

Desired Limits
$100,000/$300,000 $250,000/$250,000 $250,000/$500,000 $500,000/$500,000 $500,000/$1,000,000 $1,000,000/$1,000,000 $1,000,000/$2,000,000 $2,000,000/$2,000,000 $2,000,000/$4,000,000 Other
Desired Deductible
$500 $1000 $2500 $5000 Other $
The completion of this application or rendering of premium does not bind coverage. This application is subject to the underwriting rules of the company
WARNING - COLORADO, FLORIDA, HAWAII, KENTUCKY, LOUISIANA, MAINE, NEW JERSEY, NEW YORK, OHIO, OKLAHOMA, PENNSYLVANIA AND VIRGINIA RESIDENCES ONLY: Any person who knowingly files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information covering any fact material thereto commits a fraudulent insurance act, which is a crime (For New York residents only: 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). (For Colorado residents only: 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 reward payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies). (For Hawaii residents only: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both). (For Virginia residents only: 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.)
I have:	Answered all questions to the best of my knowledge
	Applicant represents, after inquiry, that the information contained herein and in any attachments, supplemental applications or forms required hereby are true, accurate and complete, and that no material facts have been suppressed or misstated. Applicant acknowledges a continuing obligation to report to the Company as soon as practicable any material changes in all such information, after signing the application and prior to issuance of the policy and acknowledges that the Company shall have the right to withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance based upon such changes. Further, Applicant understands and acknowledges that:
1.	if a policy is issued, the Company will have relied upon, as representations: this application; and any supplemental applications; and any other statements furnished to the Company in conjunction with this application, all of which are hereby incorporated by reference into this application and made a part hereof;
2.	this application will be the basis of the contract and will be incorporated by reference into and made a part of such policy.
	Acknowledged that this application will be the basis of the contract should the policy be issued

I acknowledge all of the above

Name

Title

Date

Sign above

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IF YOU ARE A NEW ACCOUNT:

IF YOU ARE A RENEWAL ACCOUNT:

Your Practice Information

Desired Coverage