Links
   

If you can respond "YES" to all of the eligibility statements below, you qualify for the CPA Value Plan
 

Application

for AICPA Professional Liability Insurance

To determine your eligibility, please complete the statements below. 
A member of my firm is a licensed CPA
My firm's professional staff is 3 or fewer
My firm's gross annual receipts were less than $300,000 in the last fiscal year
Firm members do not receive commissions for the referral, sale, or solicitation for sale of investments
Within the past 5 years, my firm has NOT audited any publicly held client
No more than 51% of my firm's billings are derived from Auditing
No more than 51% of my firm's billings are derived from management Advisory Services
Within the past five years, my firm has not prepared any financial statements that have been used in Initial Public, Primary, or Secondary Offerings (Include exempt transactions)

During the past five years:
My firm has had no more than two claims, and the total amount paid or reserved on these claims is less than $10,000
No firm member has been suspended from practice or been the subject of any disciplinary action
No firm member is or has been indicted or convicted of any felony charge
No firm member is aware of any circumstance that is or could be the basis for a claim
No firm member has had any professional liability insurance declined, canceled or non-renewed (Not applicable in Missouri)
My firm has NOT performed any engagement which includes remediation services on clients' computer-based systems or on the systems of third parties with whom clients transact business with respect to the Year 200 issue. See enclosed "Year2000 (Y2K) Information" Flyer. (Not applicable in Florida and Virginia)
This professional liability coverage is provided on a claims-made basis; therefore, only claims which are first made against you during the policy term are covered, subject to the policy provisions
 
If you responded "YES" to all statements above, you qualify for the CPA Value Plan. Please complete the information below. Once your application is received, we'll send you a personalized coverage and rate quotation.

If you respond "NO" to any statement above, call 1-800-786-7373 for information and the application that's right for your firm.
 
General Information
Firm Name:   Telephone:
Address:   Fax:
City:   State:
Desired Effective Date:   Zip:
      Person to contact:
Date Established:      
Check here to receive your quote via fax
 
Additional Information
Staff Size:   Professional Clerical:
Gross Annual Receipts: Last fiscal year   Estimated current fiscal year
Area of Practice: Total of all items must equal 100%
Tax   Management Advisory Services Personal Financial Planning
Bookkeeping/ Compilation General Business Planning Review
Litigation Support Services Audit (non-public clients) EDP Services/System Consultations
My firm utilizes engagement letters
Within the past 3 years, my firm has undergone a peer, quality or voluntary tax practice review under the sponsorship of the AICPA, a state CPA society or other professional organization
If "Yes", opinion rendered    
A member of my firm has attended a CNA sponsored risk management seminar in the past three years
If "Yes", most recent attendance 
At least one member of my firm is an active member of one of the following professional associations
 

Other Association:
My firm has been claim free for the past five years
My firm currently carries professional liability insurance
Insurance Carrier Policy Expiration Date Prior Acts Date

Coverage Selection:
Limits of Liability (per claim/annual aggregate)

Deductible (aggregate)

 

THE COMPLETION OF THIS APPLICATION OR TENDERING OF PREMIUM DOES NOT BIND COVERAGE. THIS APPLICATION IS SUBJECT TO THE UNDERWRITING RULES OF THE INSURANCE COMPANY.

FOR KENTUCKY, MINNESOTA, FLORIDA, PENNSYLVANIA, NEW YORK, AND OHIO RESIDENTS ONLY; ANY PERSON 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; AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION


I/We hereby declare that the above statements and particulars are true to the best of My/Our knowledge and that I/We have not suppressed or misstated any facts and I/We agree that this application shall be the basis of the contract with the Company