Professional Liability

Full Name:

*

Business Name:

*

Business Entity

Business Address:

*

Address:

*

City:

*

State:

*

Zip:

*

Contact Number:

*

Email:

*

Website:

*

Business Service Provided:
(check all that apply)

Accounting Tax Preperation Audits/Valuation Biz Consulting Biz Valuation Estate Tax Return Forensic Accounting
Litigation Support EA CPA %Bookkeeping/Payroll

When did your business begin:

*

Years of experience:

*

Professional Organization:

(AICPA, CPA Society, NATP, etc)

Number of Staff:

(F/T, P/T, Temporary - Include Owners) *

Current Carrier:

*

Date Policy Started:

(for Prior Acts) *

Requested Start Date:

*

Does your business provide the following services?: (check all that apply)

Auditing for financial instutions or pensions Financial planner or RIA Sell Tax Shelter Mergers or Acquisitions
Trustee Services Public, SEC, or High Net worth auditing

Primary Type of Client:

For the next 12 months what is your buesiness's estimated toral revenue:

*

For the next 12 months what is your estimated payroll:

*

During the last five years has a third party made a claim against your business, or you do not know of any reason why someone may make a claim.