Accountant Professional Liability Indication Form
 
 
 
 
 
 
Firm Name*
 
 
 
 
Address*
 
 
City*
 
 
 
State*
 
 
ZIP Code*
 
 
 
Phone*
 
 
Email*
 
 
 
Date Established*
 
 
Full Time or Part Time?*
 
Full Time
Part Time
 
 
 
 
 
Do you currently have Professional Liability Insurance?*
 
Yes
No
 
 
 
If Yes:
 
Insurance Company
 
 
 
 
Retroactive Date
 
 
 
 
Expiration Date
 
 
Current Premium
 
 
 
Policy Limit
 
 
Deductible
 
 
 
How many years have you had continuous coverage?
 
 
 
 
 
 
 
Percentage of income derived from the following types of practice (total =100%)
 
Audit*
 
 
Bookkeeping*
 
 
 
Fiduciary/Trustee*
 
 
Review*
 
 
 
Tax*
 
 
EDP*
 
 
 
Compilation*
 
 
Other (Specify)
 
 
 
 
 
Total Percentage of Income (Must Equal 100)*
 
 
 
 
 
 
Fees for the last fiscal year*
 
 
 
 
If you have no revenue or are currently unsure about the amount, please provide your closest approximation of expected revenue for the current fiscal year.
 
 
 
 
Total Staff (please specify how many full or part time)
 
Owners, officers, partners & CPAs
 
 
 
 
Non-CPA employees
 
 
 
 
Other employees/Clerical
 
 
 
 
 
 
 
 
 
 
 
 
 
Has the firm ever provided professional services to a financial institution, publicly traded company or insurance company?*
 
Yes
No
 
 
 
 
 
 
Total number of claims and circumstances in the last five years*
 
 
 
 
If open, amount of reserves
 
 
If closed, amount paid
 
 
 
 
 
 
Has any firm member been the subject or a complaint of disciplinary action or reprimand by any state board of accountancy or the S.E.C. or had a license or authority to practice revoked?*
 
Yes
No
 
 
 
Does any firm member receive commissions for the sale or promotion of any investment?*
 
Yes
No
 
 
 
Has the firm undergone a peer or quality review this year?*
 
Yes
No
 
 
 
Was it unqualified?*
 
Yes
No
 
 
 
 
 
 
Agency