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E & O / Professional Liability Insurance Questionnaire
Call Us Today At
(281) 550-5864
E & O / Professional Liability Insurance Questionnaire
Legal Name of Business
DBA
(FEIN) Tax ID
Owner Name
Title
Main Contact
Business Phone
Mobile Phone
Fax
Email
Website Address
Physical Address
Mailing Address
Date Business Started
Proposed Effective Date
Please indicate your preferred method of communication:
Voice / Phone
Fax
Email
Text
Legal Structure of Business Entity
Association
Corporation
Government Entity
Individual / Sole Proprietor
Limited Liability Company ( LLC )
Limited Liability Partnership (LLP)
Non Profit
Partnership
Professional Corporation
Subchapter S
Join Venture
Trust
Trustee
Detailed Description of Business
If you have a policy in force, you will need prior acts coverage. Attach a copy of your current Declarations page showing the prioracts date.
If you have coverage for any predecessor firm(s) on your current policy please attach a copy of the endorsement.
Total # of Professionals (CPAs, Public Accountants, Tax Preparers, Consultants, Enrolled Agents and Bookkeepers)
Gross Annual Revenue based on the Applicant’s fiscal year-end data (new firms provide estimate): $
The Applicant’s combined total gross revenues did not exceed $1,000,000 over the last three (3) year period.
True
False
Within the past 3 years the applicant firm has not sued any clients to collect unpaid client fees
True
False
No member or employee of the applicant firm has discretionary authority to invest or control client funds. (Bill-pay and/or payroll are acceptable and are not considered “discretionary control”).
True
False
Audit engagements generate 50% or less of the firm’s gross billings, and the firm has not performed any public audit/attest work in the last 5 years.
True
False
The applicant firm has not provided any tax advice, counsel or opinion; nor organized, sold or prepared any sales material with respect to tax shelters or other tax advantaged investments or any “reportable transaction” as defined in Treasury Reg. Sec 1.60011-4(b).
True
False
For services provided on audit engagements or non-attest services for audit clients, the applicant firm has a procedure requiring that engagement letters are used on new engagements and updated as required if the engagement changes. (If the applicant firm does not perform these services, respond “True”).
True
False
In the past 5 years, the applicant firm or any member of the firm has not performed services or consented to the use of its work product in connection with any public or private offerings of securities, real estate or other investments.
True
False
No member of the applicant firm has had their license revoked or been subject to any disciplinary action, investigation, inquiry or fine by any licensing board, regulatory agency or professional association within the past 5 years.
True
False
The applicant firm or anyone to whom this insurance will apply is not aware of any professional liability claim, or any act, omission or personal injury which might reasonably be expected to be the basis of a claim made against them within the past 5 years.
True
False
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