Global Insurance Services, Inc.

Firm Information

Name of Firm
Address
City
State
Zip
Date established:
Contact Person
Contact Telephone Number
Contact Fax Number
Email Address
Firm Telephone Number
If your firm practices from more than one office, provide the full address and the number of personnel for each location.	Type additional addresses here

1. Please indicate the number of firm personnel by the categories listed below:
CPAs		Consulting Professional
Other Accounting or Tax Professionals		Support Staff (all others)
Total Firm Personnel

2. Within the past 2 years has your firm:
a. merged with or acquired any accounting firm or other business entity?
If yes, provide details......
b. reduced the number of its owners, partners, or officers by 50% or more?
If yes, provide details......
3. Does your firm or any owner, partners or officers render services under a separate entity name?

4. Gross annual revenue for all related entities:
Last Fiscal Year
Estimated current fiscal year
Percentage from largest client (include related entities)
Client Name
Client Industry
Services Rendered
Percentage from second largest client (include related entities)
Client Name
Client Industry
Services Rendered
Estimated total number of clients for last year:

Nature of Practice

5. Areas of Practice: Provide the percentage of gross annual revenue derived from the following areas practice. (Total of all items must equal 100%)
Tax Services		Are annual engagement letters used?
Business Tax Services
Estate Tax Services
Individual Tax Services
Financial Planning and Investment Advisory Services
Financial Planning and Investment Advisory Services
If Yes, complete FINANCIAL PLANNING AND INVESTMENT ADVISORY SERVICES SUPPLEMENT
Accounting Services
Bookkeeping/Write-Up
Compilation
Attest/Assurances Services
If Yes, complete NON-PUBLIC AUDIT OR REVIEW SUPPLEMENT
Review
Audit: Non-public clients
Audit: Publicly held clients
If Yes, complete PUBLIC AUDIT CLIENT SUPPLEMENT
Forecasts/Projections
Other Attest/Assurance Services
(please describe)
Consulting Services
Business Planning
Information Technology
Business Valuation
Litigation Support
Other Consulting
(please describe)

6. Do any firm Personnel render financial planning, insurance, or investment advisory services under the firm's name or a separate entity name?
If yes, complete FINANCIAL PLANNING AND INVESTMENT ADVISORY SERVICES SUPPLEMENT
7. Within the past three years, has your firm performed audits of publicly held clients?
If Yes, complete PUBLIC AUDIT CLIENT SUPPLEMENT
8. In the past three years, has your firm or related entities provided information technology services to clients?
If Yes, complete INFORMATION TECHNOLOGY SUPPLEMENT
9. Within the past three years, has your firm performed services or consented to the use of your work product in connection with public or private offerings of securities, real estate or other investments?
If Yes, complete PUBLIC AND PRIVATE OFFERINGS SUPPLEMENT
10. Within the past three years, has any firm personnel organized, arranged or procured participants for investment ventures or participated in the management of any investment venture?
If Yes, complete INVESTMENT VENTURE SUPPLEMENT
11. Does your firm or any firm personnel control or disburse client funds?
If Yes, complete FUNDS CONTROLLED SUPPLEMENT
12. Does any firm personnel serve in the following capacities on behalf of the firm?
a. trustee or co-trustee?
If Yes, complete TRUSTEE SUPPLEMENT
b. administrator, executor, or personal representative of an estate?
If Yes, complete ESTATE SUPPLEMENT
13. Within the past three years, has the firm or firm personnel received commissions, referral fees or reciprocity or other inducements arising from the sale, promotion or recommendation of securities, real estate or other investments?
If Yes, complete please describe

14. In the last three years, has your firm provided professional services, other than tax, for a business client that subsequently declared or filed bankruptcy, defaulted on a debt obligation, or became insolvent?
If Yes, provide details below

Quality Controls

15. Indicate which of the following professional associations firm members to:
AICPA	State CPA Society	Other	None
16. Have any personnel attended an AICPA Professional Liability Risk Management Seminar within the past three years
If yes, provide:	Number of Attendees	Date of seminar
17. Within the past two years, has your firm sued to collect fees, including small claims court
If yes, provide the amount, status, reason for suit, and procedures for monitoring fees.

18. Does your firm use a published guide designed to assist in the implementation and monitoring of quality control policies and procedures in your practice?
If yes, check area(s) of practice to which the guide applies to
Accounting	Attest & Assurance	Tax	Consulting	PFP
19. Within the past 3 years has your firm undergone a peer or quality review administered by the AICPA or any state CPA society
If yes, complete section below
20. Within the past three years, has your firm performed professional services, other than tax, for any client in which firm personnel, or the spouse of firm personnel owned an equity interest or served as an officer, director, partner or other member of a governing body?
If yes, complete OUTSIDE INTEREST SUPPLEMENT
21. Within the past three years, have any past or present firm personnel been the subject of any regulatory investigation or inquiry, suspended from practice, or indicted or convicted of a felony charge?
If yes, provide details of occurrences and final action taken

Claims and Prior Insurance Information

22. After Inquiry of all firm principals, are you aware of any:
a. professional liability claims made against the firm, firm personnel or the firm's predecessors in business in the past five years?
b. act, omission or fee dispute which might reasonably be expected to be the basis of a claim or suit, against the firm, firm personnel or the firm's predecessors in business?
If yes, to A or B above complete CLAIM/INCIDENT SUPPLEMENT
23. a. Does your firm currently carry professional liability insurance?
If yes, complete section below
b. Has your firm continuously maintained professional liability coverage during the past five years?
Indicate the current prior acts date for your policy, and attach a copy of your current declarations page or prior acts endorsement:	Prior Acts Date	or Full Prior Acts
24. Has the firm or any firm personnel been declined, canceled, or non-renewed for professional liability insurance during the past three years, for any reason other than nonpayment of premium?

Coverage Selection

Indicate below your desired coverage options:
A. Limits of Liability: (Limits available up to $20,000,000 for qualified firms)
$250,000	$500,000	$1,000,000	$2,000,000			Other
B. Deductible:
Per Claim or Annual Aggregate (Deductibles available up to $250,000 for qualified firms)
$1,000	$5,000	$10,000	$25,000			Other
C. Claim Expenses
	Claim expenses reduce limits of liability
	Claim expenses in addition to limits of liability
D. Desired Effective Date:
E. Optional Employment Practice Liability Defense Coverage:		$50,000			$100,000
Complete EMPLOYMENT PRACTICES DEFENSE SUPPLEMENT
F. Optional Outside Organization Directors & Officers Defense Coverage				$1000,000
Complete D&O DEFENSE FOR NOT-FOR-PROFITS SUPPLEMENT

Notice

1.	Any claim or potential claim reported in response to question 22, or which any owners, partners, or officers of the applicant firm have any knowledge of prior or inception of any policy of CNA insurance companies will not be afforded coverage under any policy which may subsequently be issued by the CNA insurance companies.
2.	Failure to report in writing to CNA, any claim made against the applicant firm or any of the firm's personnel, or the firm's predecessors in business during the applicant firms current policy term, or facts, circumstances, or events which may give rise to a claim against the applicant firm's current insurance company BEFORE policy expiration, may be considered fraudulent and invalidate any policy which may subsequently be issued by the CNA insurance companies.

The completion of this application or the attached supplements, or tendering of premium does not bind coverage. This application is subject to the underwriting rules of the insurance company

Notice

1.	Neither the responses to this application nor any attachments thereto constitute a submission of a claim or notice of circumstances, occurrences or potential claims under any existing insurance policy. Nor does any such response indicate or imply that any claim, act or omission disclosed will be covered be this policy.
2.	Applicant's failure to report to its current insurance company any claim made against it during the current policy term, or act, omission or circumstance which Applicant is aware of which may give rise to a claim before the expiration of the current policy may create a lack of coverage.

WARNING

COLORADO, FLORIDA, HAWAII, KENTUCKY, NEW JERSEY, NEW YORK, MAINE, OHIO, OKLAHOMA, PENNSYLVANIA AND VIRGINIA RESIDENTS ONLY.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime (for new York residents only: shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation). For Colorado residents only: Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. For Hawaii residents only: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

Applicant represents, after inquiry, that the information contained herein and in any attachments, supplemental application or forms required hereby are true, accurate and complete, and that no material facts have been suppressed or misstated.
Applicant acknowledges a continuing obligation to report to the Company as soon as possible any material changes in all such information, after signing the application and prior to issuance of the policy, and acknowledges that the Company shall have the right to withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance based upon such changes.

Further, Applicant understands and acknowledges that:
1.	if a policy is issued, the Company will have relied upon, as representations: this application; and any supplemental application, and any other statements furnished to the Company in conjunction with this application, all of which are hereby incorporated by reference into this application and made a part hereof;
2.	this application will be the basis of the contract and will be incorporated by reference into and made a part of such policy;

Applicant hereby authorizes the release of claim information to the Company from any current or prior insurer of the Applicant.

IMPORTANT! Where requested, please be sure that appropriate supplements are completed

Risk Management Note

An engagement letter is often the controlling factor in determining the responsibility of both parties in malpractice claims against CPAs. Attorneys who specialize in defending malpractice claims agree that an engagement letter signed by the client before services are rendered is an effective defense tool, especially when the scope of the engagement is disputed. Accordingly, we strongly recommend using engagement letters and we offer premium credits for their use.

Click here to finish this form

The questions below this point should only be filled out if referenced from another question above. If you have completed the section above, please make sure you have filled out the appropriate additional information and click on the link above to finish the form.

Non-Public Audit or Review Section As referenced in Question 5

1. Provide the number of audit review engagements performed in the last twelve months in the following industries:
Agriculture	Construction	Employee Benefit Plans	Government

Healthcare	Manufacturing	Natural Resource Exploration	Not-for-Profit

Professional Service Firms	Real Estate	Retail	Transportation

Wholesale Distribution	List other industries and the number of clients in each one:

Back to question 5

Financial Planning & Advisory Services Section As referenced in Questions 5 & 6

Total funds under management

1.	Indicate the amount of gross revenues earned from financial planning and investment advisory services rendered by the firm, firm affiliates, and firm personnel by method of compensation.
		Last fiscal year	Current fiscal year
a.	Hourly fees and/or retainers
b.	Commissions
c.	Fee-based asset management including wrap-fees
d.	Other forms of compensation, referral fees or reciprocity*
* Indicate the compensation received, party providing compensation, and the method of triggering compensation
2.	Does your firm, firm affiliates or any firm personnel provide the following services:
a.	Refer clients to 3rd party investment advisors including broker/dealers
b.	Prepare a written financial plan
c.	Recommend specific mutual funds
d.	Recommend specific stocks, bonds, or investments other than mutual funds
e.	Provide portfolio management services
f.	Act as an agent or broker for the placement of life, accident, health or disability insurance policies or annuities
g.	Act as an agent or broker for the placement of property or casualty policies
h.	Other financial planning & investment advisory services**
** Provide a detailed description of the other services rendered
3	Is any person in your firm or any affiliated firm a registered representative/account executive for a broker or dealer?
If yes, list individuals and the name of the broker or dealer.
4	Is your firm, any affiliated firm or any firm personnel registered as an investment advisor?
If yes, identify the RIA.
5	Has any person in your firm received a professional designation specific to financial planning?
If yes, list individuals and professional designated obtained.
6	Does the firm have discretionary authority to invest client funds?
If yes, provide number of clients.
7	Does the firm obtain a signed engagement letter or contract updated annually outlining the client's investment objectives and outlining the services the firm will perform?
If no, please explain:

Back to Question 5
Back to Question 6

Public Audit Client Supplement As referenced in Question 5 & 7

1. Complete the following for all public clients for whom auditing services were provided in the past three years.
	Client 1 Name	Client 2 Name

Primary Industry
Number of years in business
Number of months as client*
Dates of audit reports issued
Type of audit reports issued (Unqualified, etc.)
Method of securities trading (List exchange, if applicable, NYSE, OTC, etc.)
* If less than three years, provide name of predecessor auditor(s) and type of audit report issued

2	Within the past twelve months, has the firm performed audit engagements for public clients which reported for the prior two fiscal years:
a.	A net loss?
b.	Negative cash flow?
c.	Negative retained earnings?
d.	Significant uncertainties or contingencies, including pending litigation or Year 2000 remediation expenditures?
If yes to any of the above, list applicable question number and identify client(s) about which your response applies, by name, trading symbol, city and state, and list the fiscal year(s)

3	For public audit engagements performed for clients which were new to your firm in the past three years, were there client disagreements with the predecessor auditor in the year prior to the change in auditors which were disclosed in SEC filings?
If yes, provide the following information:

Client Name	First year firm provided audit services	Describe nature of client disagreements as disclosed in SEC Filings (Form 8-K)

4.	For public clients audited in the past three years, has any client issued corrected financial statements or has the auditor (your firm or the predecessor) withdrawn an audit report or issued a revised audit report
If yes, identify client by name, trading symbol, industry, city and state, and list the year(s) for which the subject financial statements were corrected and/or audit reports withdrawn or revised, explaining the reason for the statement correction or audit report withdrawal/revision

5.	In the past three years, has any client company or its auditor (your firm or the predecessor) disclosed information regarding the company's ability to continue as a going concern?
If yes, identify client by name, trading symbol, industry, city and state, and explain nature of going concern reference.

6.	In the past three years, has any public client audited by the firm received a letter of comments or deficiencies from the Securities and Exchange Commission (SEC) regarding financial statement reporting or disclosure matters?
If yes, identify client by name, trading symbol, industry, city and state, and describe nature of SEC comments, clients' response and resolution.

For items 7, 8, & 9, provide the following information for public audit engagements performed by the firm (in process or completed) within the past twelve months.

List firm partners or principals responsible for supervision of public audit engagements:

Name	Years of supervisory experience in auditing public clients	Years of audit field work experience for public clients	Relevant industry experience

8.	List all firm employees who have participated in public audit engagements:

Name CPA?	Years of experience in performing public audit engagements	Relevant industry experience
		Full Time or Part Time
		Full Time or Part Time
		Full Time or Part Time
		Full Time or Part Time

9.	Does the firm belong to the SEC Practice Section of the AICPA?
10.	Does the firm use written guidelines for acceptance and continuance of public audit engagements?
	If yes, does the firm review and document its adherence to these guidelines for each client at least annually
11.	In engagement letters for the audit of public companies, does the firm specifically disclaim responsibility for the client company's Year 2000 compliance?
12.	Do management letters issued in connection with the audit of public companies specifically address the client company's need to investigate and achieve Year 2000 compliance?
13.	Do you require public audit clients to provide you with written representations acknowledging management's responsibility with respect to Year 2000 compliance, and the status of plans to investigate and achieve Year 2000 compliance?
	If yes, in what quarter and year did the firm regularly begin requiring clients to do this as a practice management tool?

Back to Question 5
Back to Question 7

Information Technology Supplement As referenced in Question 8

1.	Type of Information Technology Services	Estimated revenues from current year	Revenues from most recent year end	Revenues from 2nd most recent year end	Are annual engagement letters or contracts used?
A.	Recommending, selling, and/or training clients on computer hardware or software.
B.	Installing, modifying and/or performing regular maintenance services on computer hardware or software for clients.
C.	Designing or developing hardware or software applications for clients.
D.	Performing assessment services consisting solely of assisting clients in creating plans to investigate and achieve Year 2000 compliance for their computer-based systems excluding all testing and remediation.
E.	Performing testing or remediation services with respect to Year 2000 compliance of computer-based systems.

For any work noted under items D and E above, provide a detailed description of:
Number and description of engagements provided to date.

2.	Staffing
	List each professional who performs Information Technology Service for clients, and provide the requested information:

Name	Total years experience performing IT services	IT professional designations	IT professional education completed in last two years	Employee or Independent Contractor**
				Employee Independent
				Employee Independent
				Employee Independent
				Employee Independent
				Employee Independent

** IF Independent Contractor, please contact us to provide a certificate of insurance. Coverage under this policy does not automatically apply to Independent Contractors

3.	Do all IT engagement letters include a statement by your firm disclaiming responsibility for the client company's Year 2000 compliance?

Back to question 8

Public & Private Offerings Supplement As referenced in Question #a9

1. Please provide information for each offering of securities, real estate or other investments within the past 3 years, including non-regulated offerings:

Services Rendered	Size of Offering	Year Services Rendered	Fees Charged	Type of Offering*	Client Name	Client Industry

* If public indicate primary or secondary. If private indicate partnership, trust or stock sale.

2. Specify the years of experience of firm personnel involved in the offering of securities, real estate, or other investments described above:

Back to Question 9

Investment Venture Supplement As referenced in Question #a10

Complete the following for each investment venture firm personnel who have organized, managed, or procured participants in the past 3 years:

Name of venture & form of organization	Venture industry	Individual's role with venture	Current firm services	Net worth of venture

Do any firm clients have an ownership interest in the above ventures?
If yes, describe completely:

Back to Question 10

Funds Controlled Supplement As referenced in Question #a11

List average annual amount of client funds your firm controls or disburses:
Does the firm or any firm personnel:
1. Practice a dual signature control procedure on disbursement of funds?
2. Act as a business manager for individual clients?
  If yes, provide the number of such clients:
3. Have discretionary authority to invest client funds?
  If yes, provide the number of such clients: dollars under management If yes, provide the number of such clients:
4. Receive compensation for engagements based on any method other than hourly fees?
If yes please describe:

Back to Question 11

Trustee Supplement As referenced in Question #a12

Name of trust	Type of trust*	Dollar value of trust	Services rendered

* P= Personal/Family trusts B = Business trusts F = Foundations
C = Charities R = Real Estate

Back to Question 12

Estate Supplement As referenced in Question #a12

1. Provide information for each estate.

Name of estate	Estate Value	Beneficiary interest*

Back to Question 12

Follow up As referenced in Question 14

Name of Client	Area of Practice	Date of Service	Audit Opinion (if applicable)	Date of declaration

Back to Question 14

Follow up As referenced in Question 19

Type of Review:	Opinion Rendered:
AICPA Peer/Quality Review	Unqualified/Unmodified
SECPS	Qualified/Modified
Voluntary Tax Practice Review	Other
Other	Date Issued:

Was it an on-site review?
If a letter of comment was issued, did it contain recurring issue from the prior peer review?
If yes, provide details

Back to Question 19

Outside Interest Supplement As referenced in Question #a20

Client name:
Client Industry:
Type of services rendered:
Date services rendered
Percent of equity interest held by firm personnel or their spouse:
Capacity served by firm personnel or their spouse:
Annual fees charged to clients:

Back to Question 20

Claim/Incident Supplement As referenced in Question #a22

Complete all information for each claim or incident:

Full name of the firm personnel involved in the claim/incident:
: Full name of claimant:
Client Non-Client
: Date notified of claim: Date of alleged error:
: Name of insurer:
Date reported to insurer:
: If pending, provide: Insurers loss reserve
: If no reserve exists, provide your last settlement offer , or the claimant's last demand
: If closed, provide: Date closed .
Total claim expenses and/or settlement/loss amount paid:
: Deductible amount paid
: Claim/Incident description:

What steps have been taken to prevent similar claims?

Back to Question 22

Follow up As referenced in Question 23a

Insurance Carrier	Policy Limits

Deductible	Policy Period	Premium

Back to Question 23a

Employment Practices Defense Supplement As referenced in Coverage Selection section E

Complete only if requesting Employment Practices Defense Coverage.

1. Is your firm aware of any proposed downsizing, mergers, acquisitions which may occur within the next two years, or have you had any such activities within the past two years?
2. Have you had any claims and/or negotiated settlements, formal complaints, charges, grievances, arbitration, litigation, or administrative agency proceedings (federal, state, or local) concerning employment related issues within the past three years?
3. Are you aware of any facts, incidents, or circumstances which may result in employment related claims being made against you?
4. does your firm have in place:
a.) written procedures concerning harassment and discrimination distributed to all employee?
b.) written procedures for the handling of employee complaints of harassment or discrimination?
c.) written procedures regarding hiring, performance evaluation, disciplinary issues, and termination?
5. Does your firm currently carry employment practices liability insurance?

Back to Coverage Selection

D&O Defense for Not-For-Profits Supplement As referenced in Coverage Selection section F

Please provide the following information for each individual and entity for which coverage is requested.

a. Name of individual firm member:
b. Entity position held:
Name of entity:
Entity's activities:
Total entity revenues per year:
Does the firm provide any professional services to this entity?
Have you had any claims and/or negotiated settlements concerning D&O related issues in the past 3 years?
Are you aware of any facts, incidents, or circumstances which may result in a D&O claim being made against you?
If yes to a or b above, describe completely:
Name of entity's D & O insurance carrier:
Policy limits:
Deductible:
Prior Acts Date:

Back to Coverage Selection

Please make sure all of your information is correct, and all of the additional fields are filled in according to the referenced questions.

Click the submit button when finished.

back to the top