NOTICE: This is an application for a "Claims-made" policy. Coverage for prior acts and claims made after termination of this policy may be restricted. Please read the policy carefully.

I. General Information

Firm Name

Contact Name

Street Address

(Write separate mailing address in margin, if applicable)

Zip

City

County

State

E-mail

Website

Date Established

Phone #

Fax #

Entity Type:

CORPORATION/LLC

SOLE PROPRIETORSHIP

PARTNERSHIP/LLC

OTHER

List all firm personnel/staff (Part-time is fewer than 20 hours per week):

	CPA's		Non-CPA's
	Full Time	Part Time	Full Time	Part Time
Owners, Partners & Officers:
Employed Accounting or Tax Professionals:
Other Consulting Professionals (not included)
Administrative Staff:
Total:	{{GeneralInfo.CPATotalFullTime \| currency:"":0}}	{{GeneralInfo.CPATotalPartTime \| currency:"":0}}	{{GeneralInfo.NCPATotalFullTime \| currency:"":0}}	{{GeneralInfo.NCPATotalPartTime \| currency:"":0}}

Has the Firm’s staff size changed +/- 25% during the past three years?

Yes No

If Yes, explain:

List all additional entities for which the Applicant is seeking coverage or has assumed liabilities, including Predecessor Firms, firm name changes, merged/acquired entities, or additional business entities.

Predecessor Firm means any firm no longer in existence for which the applicant firm obtained the majority of such firm’s assets and liabilities.

N/A

	Firm Name	Date Established (mm/dd/yy)	Date Dissolved (If applicable) (mm/dd/yy)	Confirm the following: 1. Dissolved 2. Name Change 3. Continue to Exist	Percentage (%) of Assets/Liabilities Applicant Firm Assumed
#{{$index + 1}}				N/A Dissolved Name Change Continue to Exist	%

You'll need to fill the General Supplement Section 5 at the end of Coverage Request.

List the largest three (3) branch offices by gross billings:

N/A

City and State:
Billings:	$	$	$

Does the applicant firm share Office Space, Letterhead, Support Staff, or Clients with another firm?

Yes No

If Yes, provide the name and sharing relationship:

Is the entity with whom you share space separately insured for professional liability?

Yes No

Based on the Applicant’s fiscal year-end data, provide the following gross revenue figures:

Next Fiscal Year (projected)

Current Fiscal Year (estimated)

Last Fiscal Year

Previous Fiscal Year

Complete the following grid for your three largest clients as a percentage of gross annual revenue for the past 12 months:

	Name	Industry	Services Provided for Client	Percent of your Revenue Derived from Client	Number of Years you have Represented
#{{$index + 1}}				%

Complete the following grid based on the firm’s gross revenue for each category: The total must equal 100%

Type of Client	Percentage of Practice	Type of Client	Percentage of Practice
Individuals	%	Small Public Companies (<$100m revenues )	%
Individuals-High Net Worth(>$10M)	%	Large Public Companies (>$100M revenues)	%
Small Private Companies (<$100m)	%	Trusts (>$5M)	%
Large Private Companies (>$100M)	%	Other: (please specify):	%
Total	{{GeneralInfo.GR_Total \| currency:"":2}} % %

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