Accountants Professional Liability Insurance Policy Premium Estimate Questionnaire

Contact Info
Name of Applicant Firm 
Contact Name 
Phone Number 
Street Address
Address 2
Postal Code
Desired Amounts
Limits of Liability Desired (Each Claim and Annual Aggregate)
Deductible Desired (Each Claim)
Claims Expense
Additional Coverages Available by Endorsement Include
Current Insurance History

List the professional liability insurance purchased by the Applicant Firm for the past year. If ''None,'' so state.

Insurance Carrier
Inception Date
Expiration Date
Limit of Liability
No Retroactive Date
Current Policy Retroactive Date
Claim History (past 5 years)
Number of Claims
Total Estimated Dollar Amount Paid or Reserved
Any members ever had license suspended or revoked, been the subject of professional investigation, disciplinary action, paid any
Current Staffing

Indicate the total number of personnel for the Applicant Firm by full time and part time (<1,250 hours).

Total number of professional staff, including owners, partners and officers, employed by the Applicant Firm
Full Time
Part Time
Total number of additional staff, including all administrative and/or support staff, employed by the Applicant Firm
Full Time
Part Time
Gross Annual Revenue
Current Fiscal Year (estimated)
Projected Next Fiscal Year
Prior Fiscal Year
Gross Annual Revenue for the Prior Fiscal Year by Area of Practice
Area of Practice
Audit/Review Services: Public Client Audits #
Audit Services: Non-Public Clients
Business Tax Services
Estate Tax Services
Individual Tax Services
Bookkeeping and Write-Up Services
Payroll Accounting Services
Services: Non-Public Clients
Compilation Services: Non-Public Clients
Projection and Forecast Services
Valuation Services
Litigation Support Services
Business/Personal Management Services
Fiduciary Services: Trust Related
Fiduciary Services: Non-Trust Related
Fiduciary Services: Employee Benefit Plan
Information Technology Services
Securities (Other Than Audit) Services
Area of Practice
Risk Management
Are engagement letters routinely used?
Is a calendar system in place to ensure timely completion of reports, filings and tax returns?
In the past 12 months, have you sued to collect fees?
This form is for estimating purposes only. Coverage may be bound only upon submission and acceptance of a completed new business application.
Date Signed