Accountant Professional Liability
Insurance Quote Request
(Pennsylvania)
Firm Name:
Contact Person:
Mailing Address:
City:
    State:     Zipcode: 
Phone:
    Fax: 
E-Mail Address:
     Website: 
Applicant Firm is a

Coverage Selection
Liability Limit:    Deductibles: 

What date was the firm established? 

If the firm was established less than 6 years, please list....
 
Name(s) of Predecessor Firm Date(s) Formed % Owned by Current Members or Applicant Firm Did Firm Dissolved; Change Name or Form; or Continue to Exist? Last Known Professional Liability Insurer Predecessor Firm's Retroactive Date
Yes /  No
Yes /  No

Does your firm practice from additional offices?  Yes /  No

Please list here the firms staff breakdown, listing individuals in only one category...
 
Number of Full-Time Equivalent CPA's Number of Full-Time Equivalent non-CPA Accounting Professionals Number of Full-Time Equivalent non-CPA Business Consultants Number of Full-Time Equivalent Support Staff
Most recently ended fiscal year's revenues 2nd Most recently ended fiscal year's revenues
Current fiscal year's projected revenues
Total Number of Clients served in the past 12 months

Has any member of the firm or any predecessor firm been subject of a complaint, disciplinary action or reprimand by any state board, the SEC, I.R.S., governmental regulatory or tax authorities, or any accounting society?
Yes /  No
Does firm share office space with professionals/firms?
Yes /  No
If the firm shares offices with other professionals, does your firm keep separate files, employ separate support staff and present itself as an independent practice to the public?
Name of the other firm that you share space: 
Yes /  No
Have any individuals in the firm or any predecessor firm, in the past two years provided these service to any financial institution client:  
  1. any regulatory, securities or compliance services? 
  2. any services for an institution in which an Applicant member held an equity or management interest?
  3. whose deposits are not insured by a government agency such as the FDIC or NCUA?
  4. which was either in its formative stage, or which has at any point since been insolvent?
  5. for which they were an officer, director, or general counsel?
Yes /  No
Yes /  No
Yes /  No
Yes /  No
Yes /  No
How many suits for collection of fees have been filed by the firm or predecessor firms during the past 2 years?
How many of these suits have been resolved successfully?
Dollar amount of fee suits last year:               Dollar amount of fee suits the previous year: 
Has the firm, or any predecessor firm ever conducted SEC services or audits for any Publically Held Companies?
Yes /  No
Has the firm or any predecessor firm received equity or any other non-monetary compensation for the rendering of accounting services?
Yes /  No
Has the firm arranged coordinated or managed any investment venture?
Yes /  No
Within the past 6 years have any of the firms accountants served as directors, an officer, or an employee of any client; or owned an equity interest in any client; organized any investment venture; or does any client represent more than 25% of the firm's revenue?
Yes /  No
Does any member of the firm hold any professional licenses other than for accountancy?
Yes /  No
Name of Individual Profession Annual Income Derived from Profession Name of Insurance Carrier for Separate Professional Liability Insurance
Area of Practice % of Gross Receipts Engagement Letters Used
Bookkeeping
Yes /  No
Business Planning
Yes /  No
Business Taxes
Yes /  No
Business Valuations
Yes /  No
Compilation
Yes /  No
Consulting Services
Yes /  No
Estate Tax
Yes /  No
Fiduciary Services
Yes /  No
Forecasts / Projections
Yes /  No
Individual Taxes
Yes /  No
Litigation Support
Yes /  No
Other Types of Audit
Yes /  No
Other Attest/Assurance Services
Yes /  No
Other Services (Describe: )
Yes /  No
Personal Financial Planning & Investment Advisory Services
Yes /  No
Public Company Audit
Yes /  No
Review
Yes /  No
Sarbanes-Oxley Consulting
Yes /  No
Securities Activities
Yes /  No
 

You can also fax this completed form to 1-888-800-0034

M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway       Murrysville, PA.   15668-1890
(724) 327-8474   Fax: (724) 327-7911
Toll Free: 1-800-977-2999       Fax: 1-888-800-0034

http://www.McGrathInsuranceGroup.com             McGrathInsurance@verizon.net