Accountants Insurance Premium Indication Request

Firm Name*

Contact*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Fax

Email*

Annual Fees

In the past 3 years, how many firm members have attended a loss control seminar?

On what date was the firm established?

Within the past 5 years has the firm provided services to a client that is engaged in the issuance, offering, registration or sale of securities or bonds; or provided clients with forecasts or projections for inclusion in sales literature, etc., of any securities or bonds?

Yes
No

Has any member of the firm provided services or acted as a director/officer/committee member for any financial institution?

Yes
No

Has any member of the firm had an accounting license or authority to practice accounting revoked, or been subject to disciplinary action, fine reprimand, or criminal penalty related to performance of professional services?

Yes
No

Full Time Accountants

Number of Full Time Accounts With 5+ Years Experience

Number of Full Time Accounts With 4 Years Experience

Number of Full Time Accounts With 3 Years Experience

Number of Full Time Accounts With 2 Years Experience

Number of Full Time Accounts With 1 Year of Experience

Number of Full Time Accounts With Less Than 1 Year of Experience

Part Time Accountants

Average of 25 hours per week or less

Number of Part Time Accountants With 5+ Years Experience

Number of Part Time Accountants With 4 Years Experience

Number of Part Time Accountants With 3 Years Experience

Number of Part Time Accountants With 2 Years Experience

Number of Part Time Accountants With 1 Year of Experience

Number of Part Time Accountants With Less Than 1 Year of Experience

Renewal Date

Insurer

Limit

Deductible

Premium