CPA Application

Professional Liability Premium Indication for CPAs
Application for AICPA Value Plan

Central Florida Firms only please

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

During the past five years:
- My firm had no more than two claims, and the total amount paid or reserved on these claims is less than $10,000	yes no
- No firm member has been suspended from practice or been subject of any disciplinary action	yes no
- No firm member is or has been indicted or convicted of any felony charge	yes no
- No firm member is aware of any circumstance that is or could be the basis for a claim	yes no
- No firm member has had any professional liability insurance declined, canceled or non-renewed (Not applicable in Missouri)	yes no
- My firm has NOT performed any agreement 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 2000 issue	yes no

* If you responded "yes" to all statements above, you qualify for the CPA Value Plan. Please complete the information below and submit the form to us. Once your application is received, we'll send you a personalized coverage and rate quotation.

* If you responded "no" to any statement above, call us at (407) 647-1616 and speak to Karen James
or contact us for information and the application that's right for your firm.

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.

Firm Name

Contact Name

Address

City

State

Zip


Phone	Fax	email


Date Established

1. Staff size: Professional Clerical

2. Gross Annual Receipts: Last fiscal year $ Estimated current $

3. Areas of Practice: Total of all items must equal 100%.

Tax	%	Management Advisory Services	%
Personal Financial Planning	%	EDP Services/System Consultations	%
Bookkeeping/Compilation	%	General Business Planning	%
Review	%	Litigation Support Services	%
Audit (non-public clients)	%

4. My firm utilizes engagement letters on the majority of engagements yes no

5. 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. yes no
If "yes", opinion rendered: Unqualified Modified Other

6. A member of my firm has attended a CNA sponsored risk management seminar in the
last three years. yes no
If "yes", most recent attendance

7. At least one member of my firm is an active member of one of the following professional
associations yes no
AICPA State CPA Society Other

8. My firm has been claim free for the past five years. yes no

9. My firm currently carries professional liability insurance. yes no

If "yes," provide:	Insurance Carrier
	Policy Expiration Date Prior Acts Date

10. Coverage Selection:	Limits of Liability (per claim/annual aggregate)	Deductible (aggregate)
	$100,000/$250,000	$0
	$250,000/$500,000	$1,000
	$500,000/$1,000,000	$5,000
	$1,000,000/$2,000,000

If you have completed the form as fully as possible, click the Submit button to send us your information.

Florida Insurance Agents only please.