Accountants Online Estimate Form


ACCOUNTANTS
INVESTMENT ADVISOR
BOOKKEEPERS/TAX PREPARERS
ATTORNEYS
IP ATTORNEYS
ARCHITECTS/ ENGINEERS
HOME INSPECTORS
OTHER PROFESSIONS


EMPLOYMENT PRACTICES
EMPLOYEE DISHONESTY
FIDUCIARY LIABILITY
DIRECTORS & OFFICERS LIABILITY


CLIENT RESOURCES

Online Indication Form

Complete our online estimate form and we will provide you with a no-obligation competitive insurance premium indication.

Firm Information:

Firm:
Contact:
Address:
City:		State:
County:		Zip:
Phone:
Fax:
Email:
Website:

Please provide your firm's annual fees

Annual Fees from last filed tax return	Y/E

Annual Fees estimated for current year	Y/E

Please provide the number of Accounting Professionals within your firm (list only CPA's, EA's, PA's and other professionals with 4 year accounting degrees), and the number of years they have been with the firm. (For part-time professionals use decimals)

Number of Accountants	Years with firm (year joined)
	5 or more
	4 years
	3 years
	2 year
	1 year

Please tell us the approximate percentage of income received from the following activities for the last annual period. (Please express percentages in whole numbers. Total must equal 100%)

Activity	%	Activity	%
Audit: Public Companies		Litigation Support
Audit: Other		Management Advisory Services
Review		Assurance Services
Compilation		Financial Planning
Bookkeeping		Asset Management
Tax		Sale of Mutual Funds
Business Valuation		SEC Related
Computer Consulting		Other
		Total	100%

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 any accounting license or authority to practice accounting revoked, or been subject to disciplinary action, fine, reprimanded, or criminal penalty related to performance of professional services?	Yes	No
Do engagement letters contain an Alternative Dispute Resolution Clause?	Yes	No

Have you had or reported any Professional Liability claims in the last five years?

Yes	No	One	Two	Three
Date claim/s reported
Amount paid, including defense expenses (if closed)
Reserve amount (if open)

Insurance Information

Current Insurance Carrier
Current Insurance Agent
Policy Expiration date
Number of years insured (retroactive date)
Current limits
Claims expenses in addition to, or inside limit?	Inside limit	Outside limit
Current deductible
Current premium


Have you spoken with a NAPLIA representative?	Yes	No
Who



Accountants Professional Liability Insurance \| Attorneys Professional Liability Insurance \| Intellectual Property Attorneys Professional Liability Insurance \| Design Professionals Liability Insurance \| Other Professional Liability Insurance \| Employment Practices Professional Liability Insurance \| Employee Dishonesty Professional Liability Insurance \| Fiduciary Professional Liability Insurance
North American Professional Liability Insurance Agency, LLC 1-866-262-7542 Copyright 2004 - 2007