ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION

1. Legal Name of Applicant Firm
   Address (street number and name, apt #)
   Address2 (city, state, zip)

   New Application    Renewal

   Policy Period From Date Pick a date    To Date Pick a date   (click calendar icon to enter the dates)

   Retroactive Date Pick a date

2. Year firm established:

3. Does your Firm practice from any other office location(s)? YES    NO
    if yes, please provide addresses of other locations:

4. Firm is a(n): Sole Proprietor    Partnership    Professional Corporation or Association    Limited Liability Company
             Limited Liability Partnership    Other

5. Has your name ever changed or have you merged with or acquired another Firm?
     YES    NO
    if yes, please provide complete details including full legal names, dates of operation, etc.

6. Limits of Liability (Per Claim/ Aggregate): $100,000    $250,000    $500,000    $1,000,000    $2,000,000
     $3,000,000    $4,000,000    $5,000,000    $10,000,000
     Other $

7. Deductible Amount Requested. (PER CLAIM ) $1,000    $2,500    $5,000    $10,000    $15,000
     $20,000    $25,000    Other : $

8. Do you share office space, expenses or staff with any other accountant(s) or with any other professionals?
    YES    NO
    If “Yes”, please describe arrangement and identify by name the space/expense sharer(s):

9. Is this a full-time Accounting or Bookkeeping practice? YES    NO

10. Does any member of your Firm provide professional services as a practicing lawyer, real estate agent or broker,
     investment advisor, or securities agent or broker?
     YES    NO
     If “Yes”, please provide complete details including whether covered by a separate professional liability policy

11. Total number of Professional Staff engaged in Accounting or Bookkeeping is:
      Please list all personnel by Category (from all offices).

12. a. Indicate the gross billable income for the applicable fiscal year.
Last Fiscal Year Current Fiscal Year Next 12 Months Projected
Ending: Pick a date    Ending: Pick a date    Ending: Pick a date   
  GBI: $   GBI: $   GBI: $

    b. Total # of clients for the past year.
        If newly established, please estimate # of clients for next year.

13. Do you have any single client(s) representing 25% or more of your gross billable income?
     YES    NO

    If “Yes”, please provide client(s) profile, services performed by you, % of your revenue, etc.

14. Indicate the approximate % of your last year’s billings and whether Engagement Letters are used. Total percentage must add up to 100%.
Area of Practice % of Income Engagement Letters Used?
A. AUDITS
Municipal % Yes    No
Publicly-Held Companies * % Yes    No
Other % Yes    No
B. GENERAL
Bookkeeping/Write-ups % Yes    No
Reviews % Yes    No
Compilations % Yes    No
Personal Financial Planning % Yes    No
C. TAX SERVICES
Individual/Estate Returns % Yes    No
Corporate Returns % Yes    No
Limited Partnership Returns % Yes    No
D. BUSINESS ACQUISITIONS
Divestitures % Yes    No
Evaluations & Projections % Yes    No
E. MANAGEMENT ADVISORY SERVICES
Please Describe: % Yes    No
F. EDP/COMPUTER SERVICES
Hardware/Software Sales % Yes    No
Data Processing Service % Yes    No
Hardware/Software Consulting % Yes    No
G. FIDUCIARY SERVICES
Administrator, Executor or ERISA Trustee % Yes    No
Bankruptcy Trustee or Receiver % Yes    No
H. SECURITIES ACTIVITIES *
Limited Partnership & Tax Shelter Syndication * % Yes    No
Debenture Financing/Bonds * % Yes    No
Securities including Federal & State Securities * % Yes    No
I. OTHER
Please Describe: % Yes    No
TOTAL 100%  


15. What percentage of your billings are derived from the following client types?
Individuals %
Healthcare/HMO’s % Construction Concerns %
Privately-Held Companies % Real Estate Concerns %
Financial Institutions % Publicly-Held Companies %
Non-Profit Organizations % Other (Describe) %

16. Have you provided professional services (including but not limited to audits) to a publicly traded client
     in connection with the registration, sale or offering of securities for clients or in connection with the offer
    and sale of private placement bonds?
     17. Excluding activities as a trustee or receiver, has any client been the subject of bankruptcy, insolvency or
    receivership proceedings within the past three (3) years?
     Yes   No
     If “Yes”, please provide date of client’s bankruptcy, insolvency or receivership, services performed by you,
      date of first engagement and whether an engagement letter was used (if not, please explain)

18. Within the past five (5) years, have you:
      a. received commissions, fees, reciprocity or revenue for referrals, sale or promotion of investments or tax shelters?
      Yes   No
      b. organized, arranged, procured or evaluated investments, real estate or tax shelters or prepared projections for use in these areas?
      Yes   No
      c. participated in the management of any investment partnership, limited partnership, tax shelter or other investment venture?
      Yes   No
      d. received loans from any client?
      Yes   No
      e. made recommendations as to the sale or purchase of any investments, including specific stocks, bonds or other securities
         for which you received compensation?
      Yes   No
      If you answered “Yes” to any part of this question, please provide complete details here:

19. Within the past five (5) years, have you invested, received, disbursed or in any way acted in a decision-making capacity
      with respect to a client’s funds?
      Yes   No
      If “Yes”, please indicate name of client, amount of funds, services performed by you, check signing authority (dual or sole),
      whether distributions are under a trust agreement, and whether you are bonded for the handling of client’s funds (if so,
      indicate carrier and bond amount)

20. Does or has any member of the Firm served as trustee or performed professional services to any client(s) in which any
      Firm member or spouse serves as trustee?
      Yes   No
      If “Yes”, please complete the Trustee Supplement.

21. Has any member or former member of the Firm, provided auditing or any consulting services to, acted as a Director
      or Officer of or been a committee member of any Financial Institution in the past 5 years?
     Yes   No
      If “Yes”, please complete the Financial Institution Supplement.

22. Has the Applicant Firm performed any professional service(s) in which any member of the Applicant Firm or his/her
      relative or spouse served as an officer, director, manager, owner, employee or contractor, or had a financial
      interest in the client firm?
      Yes    No
      If “Yes”, please complete the Outside Interest Supplement.

23. Do you anticipate, within the next (12) months, any material changes to the Firm or its practice?
      Yes    No
      If “Yes”, please provide a complete description

24. Within the past (3) years, have you had a quality peer review? Yes    No
     a. Was the review unqualified? Yes    No
       Please send an email to Gross Insurance and attach a copy of the peer review and any response you may have had to recommendations.

25. Please indicate method(s) used to identify any actual or potential conflicts of interest:
     Oral / Memory   Computer    Index File    Conflict Committee
     None    Other

26. In the past five (5) years, has any professional liability claim or suit been made against the Firm, any
     predecessor in business or any current or former partner, officer, shareholder or employed accountant?
     Yes    No
     If “Yes”, please complete the Claim Supplement for each claim.

27. Does any Accountant for whom coverage is sought know of any incident, act, error or omission that could
     result in a claim or suit against the Applicant Firm or any predecessor firm or any of the current or former members
     of the firm?
     Yes    No
     If “Yes”, please complete the Claim Supplement for each claim or incident.

28. Within the past (5) years, have you sued to collect fees or threatened to do so?
     Yes    No
     If “Yes”, please describe all collection suits including Name of clients, Services rendered, Dates of services,
     Suit date, Fee amounts, Status or outcome of suit and whether your firm is still providing services for this client.

29. List the Accountants Professional Liability Insurance Coverage carried during the past five (5) years, including any
     periods without coverage. If no past coverage, please indicate NONE. If current coverage is in place, please provide
     evidence of your professional liability insurance.
  Policy Period (click calendar for dates) Insurance Company Limits of Liability Deductible/
Retention		 Premium
Current Year Pick a date   To  Pick a date
Prior Year 1 Pick a date   To  Pick a date
Prior Year 2 Pick a date   To  Pick a date
Prior Year 3 Pick a date   To  Pick a date
Prior Year 4 Pick a date   To  Pick a date


30. In the past five (5) years, has the Firm or any Firm member ever had Professional Liability insurance or similar
     insurance declined, canceled or non-renewed?
     Yes    No
     If “Yes”, please explain.

31. Has any Accountant for whom coverage is being sought ever had their accounting license suspended or revoked;
     or been subject to any investigation by any board of accounting, AICPA, SEC, State CPA Society or any other
     governmental agency, or court; or been subject to any reprimand, criminal penalty or fine (including a tax preparer’s
     fine); or been convicted of any felony charge or are they currently under indictment?.
     Yes    No
     If “Yes”, please provide complete details.

NOTICE TO APPLICANT - PLEASE CLICK TO OPEN, READ VERY CAREFULLY,
AND CHECK BOX INDICATING YOU HAVE READ THIS.
I have read this notice.

Signature:    Print Name:
(Must be signed by a Sole Proprietor, Partner, Member or Officer of the Applicant Firm.)
Title:   Date: