APPLICATION FORM. Professional Indemnity Insurance

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1 APPLICATION FORM Professional Indemnity Insurance Accountants/Auditors Instructions to the applicant. A. Please answer all questions. The information is required to make an underwriting and pricing evaluation. Your answers hereunder are considered legally material to that evaluation. B. If a question is not applicable, state N/A. If more space is required to answer a question please attach exhibit with question number. C. A principal of the Firm must sign and date this form and any separate sheet. D. DOCUMENT CHECKLIST This application, fully completed, signed and dated. A sheet of your firm s current Headed tepaper. Fully completed claim forms for all circumstances, incidents or claims reported to other Insurers by your firm and any predecessor firm (prior practice). CV of principals, officers and professional staff The Internal Control and/or Quality Control Procedures Copy of standard contract and engagement/proposal letter used with clients List of the listed accounts that you audit. 1

2 Section I The Company 1. Please state the name of the Company 2. Address, website and address 3. Please state name of all subsidiaries to be covered by the insurance. If you have offices abroad please provide information whether local policies are in place. 4. The Applicant is: Corporation Partnership Individual 5. Date the firm was established 6. Is cover required for liabilities arising from any predecessor in business? If yes, please inform about the name of the firm, the date of establishment and the date the firm were succeeded. 7. Fees Please state the firm s gross fees. 8. Fees What is your largest fee for a single client? 2

3 9. Please include a list of the firm s five largest assignments during the past three years Client Name Activities performed for the client Fees Section II Partners and employees 10. Please state name of all partners and the year the person became partner Name Year 3

4 Name Year 11. Please state the following Number of Partners Number of qualified Accountants/Auditors (excluding Partners) Number of Consultants Number of other staff 4

5 Section III Operations 12. Please state percentage () of total income relating to the following areas of practice Aucconting/Audits a) Listed Companies* b) Unlisted Companies c) Financial Institutions d) Unincorporated small business e) Other (please describe) Tax Services a) Individual Returns b) Corporate Returns c) Limited Partnership Returns d) Other (please describe) Accounting and Bookkeeping Investment Advice Fund Management Mergers & Acquisitions Pensions Advice Management Consulting IT Consulting Other (Please describe on a separate sheet) Total (Please describe on a separate sheet if above five percent) 100 * Please provide a list of the companies you audit that are listed. 13. Do you provide or have you provided management services or investment advice to any entertainment clients or sporting professionals? If yes, please provide full details of the client and the work undertaken. 5

6 14. Do any one client generate 10 or more of your annual fees? If yes, please provide full details of the client and the work undertaken. 15. Do you have any cooperative agreement with any other accounting firm or law firm? If yes, please provide full information. 16. To what professional association(s) does the Applicant belong? 17. Please state number of cases per year 18. Please state number of clients per year for the last two years 19. Has there been any significant changes in your firm during the last ten years? Do you expect any significant change in your firm? If yes, please provide full information. 6

7 20. Excluding activities as a trustee or a receiver, please attach the following information for each client, which has been the subject of bankruptcy, insolvency or receivership proceedings within the past three (3) years. Please complete the following: I Date of client s bankruptcy, insolvency or receivership II Services rendered by the Applicant III Client s annual sale for the last three (3) years IV Date of first engagement letter V Was an engagement letter used? Section IV Risk Management 21. Do you have a planned system to meet deadlines? If yes, please provide full information. 22. Within the last six (6) years, has the Applicant had a peer review or a quality review? If yes, please provide details of the outcome. 23. What steps are taken to minimize a potential liability risk? Please provide detailed information/documentation concerning your risk management, internal guidelines and compliance directives. 24. Who is responsible for risk management? To whom is the Risk Manager reporting? 7

8 25. How is the internal reporting organised in case a client is not satisfied with your services and/or a claim has been (or might be) reported? 26. What is the corporate philosophy for taking on other services (consulting etc.) except auditing/accounting for the same client? 27. Describe the firm s client selection process a.does the firm perform credit checks on all clients? b. Is Management Approval required for all new clients? c. Does the firm maintain a system to avoid conflict of interests? d. Does your firm use letters of appointment, client communication letters to include scope of service and fee arrangements? e. Does your firm use declination letters for cases where representation is declined? 8

9 Section V Disciplinary 28. Has any accountant or other member of staff, either past or present, ever been the subject of disciplinary proceedings by a professional organisation or had a civil or criminal judgement against him or her? If yes, please enclose full particulars. 29. Has any partner or member of staff, been involved in any instances of fraud or dishonesty? If yes, please enclose full particulars. Section VI Claims 30. In the past five years, has any claim or suit ever been made against any current or previous member of the firm? If yes, please enclose full particulars. 31. Are you aware of any circumstances, incidents or claims that, after making full enquiry of all principals and employees of your firm, you have not reported to your current or prior insurer? If yes, please enclose full particulars. 32. Are you aware of any circumstances, incidents or claims that, after making full enquiry of all principals and employees, that could result in a professional indemnity claim against any one in the firm? If yes, please enclose full particulars. 33. Has the firm or any one employed by the firm ever had any professional indemnity insurance company decline, cancel or refuse to renew? If yes, please enclose details. Section VIII - Insurance Cover 34. Are you presently insured for professional liability? If, please state limit of liability, deductible and due date Limit of liability: Deductible: Expiry date: Premium: 35. Do you request primary coverage or excess coverage? Primary coverage Excess coverage 36. If primary coverage is requested, please state requested limit of liability per claim and annual aggregate and requested deductible per claim Limit of liability per claim and Annual aggregate: Deductible per claim: 9

10 37. If excess coverage is requested, please state name of primary insurer, requested limit of liability in excess of underlying coverage, underlying limit of liability and deductible and insurance period Please enclose the full policy wording for the primary insurance. Name of Primary Insurer: Requested limit of liability in excess of underlying coverage: Underlying limit of liability and deductible: Insurance period: Premium: Section VIII 38. The undersigned on behalf of the applicant and all members of the firm hereby declares that he/she is authorised to make the following declarations and representations on behalf of the firm and its members. We hereby declare that the above answers, statements and particulars in this application are complete and true, and that no material facts have been suppressed, omitted or misstated. The firm has made specific inquiry to all accountants in the firm as to their knowledge of any matters, which could result in a claim against the firm in the future. All accountants have answered in the negative to such inquiry or where accountants have responded other than in negative, the matters identified has been reported to the firm s current insurer. All such matters are listed in supplements to this application, and the firm acknowledges, understands and agrees that any and all claims arising out of such matters will be excluded from the Policy being applied for and any renewals of said Policy. It is agreed that this application, together with any other information supplied by us, shall form the basis of the contract, should a policy be issued, and it will be attached to and form part of the policy. Signing this application does not bind the company or the insurer to complete the insurance. Date and place: Signature: Name and Title: 10

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