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AccountPro Carolina Casualty Insurance Company (RT Specialty)

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Carolina Casualty Insurance Company
4600 Touchton Road East, Building 100, Suite 400, Jacksonville, FL 32246
AccountPro
Proposal Form
Accountants Professional Liability Insurance
CLAIMS MADE WARNING FOR APPLICATION
THIS PROPOSAL FORM IS FOR A CLAIMS MADE AND REPORTED POLICY, RELATING TO CLAIMS MADE AGAINST
THE INSUREDS DURING THE POLICY PERIOD OR ANY EXTENDED REPORTING PERIOD THAT MAY APPLY.
APL 28500 (rev. 11-07) Page 1 of 6
Whenever printed in this Proposal Form, the terms in boldface type shall have the same meanings as indicated in the Policy. This Proposal Form is
to be completed with respect to the entire Applicant Firm.
Name of Applicant Firm
Street Address Suite
City County State Zip Code
Website Address (if applicable) Federal Employer Identification Number (FEIN)
The person designated as agent of the Applicant Firm and of all Insureds to receive any and all notices from the Insurer or their authorized
representatives concerning this insurance:
Contact Name Title
E-mail Address Telephone Number Fax Number
Producer Information
Submitted by (Agency Name) Dated
Agent’s Name (Individual’s Name) Agent’s License Number
Coverage Requested (Indicate all options desired)
Limits of Liability Desired (Each Claim and Annual Aggregate):
$100,000 / $100,000 $100,000 / $200,000 $100,000 / $300,000 $250,000 / $250,000
$250,000 / $500,000 $500,000 / $500,000 $500,000 / $1,000,000 $1,000,000 / $1,000,000
$1,000,000 / $2,000,000 $2,000,000 / $2,000,000 $3,000,000 / $3,000,000 Other: $________________
Deductible Desired (Each Claim):
$0 $1,000 $2,500 $5,000
$10,000 $15,000 $20,000 Other: $________________
First Dollar Claim Expense (Damages Only) Deductible:
Yes No
Claims Expense:
Inside the Limit Outside the Limit Both Options Desired
Additional Coverage Requested
Additional Coverage
Coverage
Requested?
Proposal Form Required
Employment Practices Liability Claims Expense
Yes No
Employment Practices Liability Proposal Form (APL 28780)
Life Insurance Agent Professional Liability
Yes No
Additional Entity / Individual License Proposal Form (APL 28700)
Nonprofit Directorship Liability Claims Expense
Yes No
Nonprofit Directorship Liability Proposal Form (APL 28750)
Real Estate Agent Professional Liability
Yes No
Additional Entity / Individual License Proposal Form (APL 28700)
Registered Representative Professional Liability
Yes No
Registered Representative Proposal Form (APL 28810)
Current Insurance Information (Provide details to all “Yes” answers)
1. List the professional liability insurance purchased by the Applicant Firm for each of the past 3 years. If “None”, so state.
None
Insurance Carrier
Inception Date
Expiration Date
Limit of Liability Deductible
Premium
$ $
$
$ $
$
$ $
$
Reset
Carolina Casualty Insurance Company
APL 28500 (rev. 11-07) Page 2 of 6
2. Has the Extended Reporting Period (or Discovery Period) been exercised for any of the Applicant Firm’s, or any predecessor
in business, prior professional liability insurance policies?
Yes No
If “Yes”, provide full details.
3. Within the last 3 years, has the Applicant Firm, or any predecessor in business, ever had an insurer decline, cancel, refuse to
renew, rescind, or accept only on special terms, any professional liability insurance policy? (
NOT APPLICABLE IN MISSOURI)
Yes No
If “Yes”, provide full details.
4. Does the Applicant Firm's current or most recently expired professional liability insurance policy contain a retroactive date?
Yes No
If “Yes”, indicate the date (Mo/Day/Yr):
General Information (Provide details to all “Yes” answers by attachment, when appropriate)
5. Form of Applicant Firm:
Corporation Partnership Professional Corporation
Limited Liability Corporation Professional Association Sole Proprietorship / Individual
Limited Liability Partnership Other:______________________________________________
6. The Applicant Firm has been in continuous operation since:
7. Does the Applicant Firm share office space with any other entity / person?
Yes No
(a) If “Yes”, does the Applicant Firm keep separate files, employ separate staff and present itself as an independent
practice to the public?
Yes No
(b) If “No”, complete the Multiple / Shared Office Supplemental Form (APL 28720).
8. Within the last 5 years, has the Applicant Firm:
(a) changed its name?
Yes No
(b) experienced a change in ownership or principals?
Yes No
(c) merged with or acquired, the business of any individual or entity?
Yes No
9. Provide the following on all
Predecessor Firm(s) to whose assets and liabilities the Applicant Firm is the majority successor
in interest. Include the date the Predecessor Firm(s) were acquired. If “None”, so state.
None
Name of Predecessor Firm
Date
Acquired
Prior Acts Coverage
Requested
Yes No
Yes No
Yes No
10. Does the Applicant Firm have any affiliates and/or subsidiaries?
Yes No
If “Yes”, and coverage is requested, complete the Additional Entity / Individual License Supplemental Form (APL 28700) for
each entity proposed for coverage.
11. Is the Applicant Firm, any Predecessor Firm, subsidiary, affiliated entity, or any member of the Applicant Firm engaged in
any of the following activities? If “None”, so state.
None
Registered Representative Real Estate Agent / Agency Life Insurance Agent / Agency Lawyer
Investment Advisor Title Insurance Agent / Agency Other: ____________________________________________
12. Indicate which professional association(s) the Applicant Firm or at least one member of the Application Firm is an active
member of. If “None”, so state.
None
AICPA State CPA Society National Society of Accountants
National Association of Tax Professionals National Association of Enrolled Agents American Taxation Association
American Payroll Association American Institute of Professional Bookkeepers
13. Indicate active American Institute of Certified Public Accountants (AICPA) section membership(s). If “None”, so state.
None
Center for Public Company Audit Firms Government Audit Quality Center
Employee Benefit Plan Audit Quality Center Private Companies Practice Section
Current Staffing Information
14. Indicate the total number of personnel for the Applicant Firm by Full Time and Part Time (<1,250 hours).
(a) Total number of Professional Staff for the Applicant Firm. FT PT
Owners, Partners and Officers (#_____ CPAs; #_____ Public Accountants; #_____ Tax Professionals):
Employed Certified Public Accountants (not included above):
Other Accounting or Tax Professionals (not included above):
Independent Contractors and Temporary Staff:
(b) Total number of Additional Staff for the Applicant Firm. FT PT
Administrative / Support Staff:
Leased, Seasonal, and Temporary Staff:
Carolina Casualty Insurance Company
APL 28500 (rev. 11-07) Page 3 of 6
15. Within the last 5 years, has the professional staff of the Applicant Firm changed +/- 30 percent, which was not related to any
merger or acquisition activity? Not applicable to firms with less than 10 professionals.
Yes No
16. List the following information for each Owner, Partner, and Officer of the Applicant Firm.
Name(s)
# Years in Practice State(s) where License(s) Apply
#
#
#
#
Nature of Practice Information
17. Indicate the Gross Annual Revenue for the Applicant Firm.
Prior Fiscal Year
Current Fiscal Year (estimated) Projected Next Fiscal Year
$ $ $
18. Indicate the percentage of revenue for the Prior Fiscal Year from the largest clients for the Applicant Firm.
Largest Client % of Revenue % Second Largest Client % of Revenue %
Type of Industry Type of Industry
Number Years as Client Number Years as Client
19. Indicate the percentage of revenue for the Prior Fiscal Year from the largest states for the Applicant Firm.
State % of Revenue State % of Revenue
%
%
%
%
20. Indicate the percentage of Gross Annual Revenue for the Prior Fiscal Year derived from the following areas of practice:
Area of Practice
%
Area of Practice
%
Business Tax Services % Litigation Support Services %
Estate Tax Services % Business / Personal Management Services (1) %
Individual Tax Services % *Fiduciary Services: Trust Related %
Bookkeeping and Write-Up Services % *Fiduciary Services: Non-Trust Related %
Payroll Accounting Services % *Fiduciary Services: Employee Benefit Plan (7) %
Audit / Review Services: Public Clients (2) % Information Technology Services (6) %
Audit Services: Non Public Clients (3) % Assurance Services (5) %
Review Services: Non Public Clients % Securities (Other than Audit) Services (4) %
Compilation Services: Non Public Clients % Other: _______________________________ %
Projection and Forecast Services % Other: _______________________________ %
Business Valuation Services % *Describe services by attachment. TOTAL: 100%
Complete the following Supplemental / Proposal Form(s), as indicated above: (1) Business / Personal Management (APL 28800); (2) Public Client Audit
Services (APL 28740); (3) Non Public Client Audit Services (APL 28730); (4) Securities Services (APL 28820); (5) Assurance Services (APL 28830);
(6) Information Technology Services (APL 28840); Employee Benefit Plan (APL 28790).
Public Client Services include: audit, review or forecast / projection engagements performed in connection with, but not limited to: (1) Registration
Statement(s) filed with the Securities and Exchange Commission (“SEC”) or similar State Securities Commission, or (2) Report(s) filed with the SEC, any
State Securities Commission, NASD or any Stock Exchange, or similar organization.
21. With respect to the areas of practice listed above (Provide details to all “Yes” answers by attachment.):
(a) have any of the professional services provided changed by more than 25 percent during the last 5 years?
Yes No
(b) does the Applicant Firm foresee a 25 percent change in the professional services provided in the next 12 months?
Yes No
(c) have there been any professional services previously provided that have been discontinued in the last 5 years?
Yes No
(d) are there any plans to expand professional services into new areas in the next 12 months?
Yes No
22. Is the Applicant Firm, if required, properly licensed and in good standing for the state(s) in which it operates?
Yes No
23. Within the last 5 years, has the Applicant Firm, any Predecessor Firm, or any member of the Applicant Firm:
(a) performed services, other than tax, for a client that is contemplating or has declared or filed bankruptcy, defaulted on a
debt obligation, or become insolvent?
Yes No
(b) performed services for any financial institutions (e.g., Banks, Bank Holding Companies, Savings & Loans, Savings
Bank, Credit Unions or Insurance Companies)?
Yes No
(c) performed services or consented to the use of the Applicant Firm’s work product, in connection with public or private
offerings of securities, real estate, or other investments?
Yes No
If “Yes”, complete the Securities Services Supplemental Form (APL 28820).
(d) exercised any discretionary control over client funds, other than as an executor or trustee?
Yes No
Carolina Casualty Insurance Company
APL 28500 (rev. 11-07) Page 4 of 6
24. Within the last 5 years, has the Applicant Firm, any Predecessor Firm, or any member of the Applicant Firm (including members of their
immediate family):
(a) held an equity interest in any entity, organization, corporation or enterprise (including any current or former clients) to
which the Applicant Firm has rendered services?
Yes No
(b) served as a director or officer, or served in a fiduciary capacity, in any entity, organization, corporation or enterprise
(including any current or former clients) to which the Applicant Firm has rendered services?
Yes No
(c) exercised any managerial control over any entity, organization, corporation or enterprise (including any current or
former clients) to which the Applicant Firm has rendered services?
Yes No
If “Yes” to any of the above, complete the Outside Interests / Activities Supplemental Form (APL 28710).
25. Within the last 3 years, has the Applicant Firm, any Predecessor Firm, or any member of the Applicant Firm:
(a) organized, promoted, solicited on behalf of or procured participants for investment ventures?
Yes No
(b) provided management services for investment ventures?
Yes No
(c) participated with clients in any investment or business?
Yes No
(d) arranged debt or equity financing or acted as a business broker?
Yes No
(e) received commissions, referral fees, reciprocity or other inducements arising from the sale, promotion or
recommendation of securities, insurance products, real estate or other investments?
Yes No
(f) organized, sold, acted as sales promoter or sales agent for, or acted as manager or general partner for any real estate
or other investment syndicate, limited liability company or partnership (limited or general)?
Yes No
(g) organized, sold, acted as sales promoter or sales agent for, prepared any promotional sales materials for, provided any
tax advice, counsel or opinions with respect to, or prepared or assisted in preparing any income, gift or estate tax
returns incorporating or reporting a tax shelter or other tax advantaged investment which provided taxable income
exclusions or tax deductions exceeding $500,000 in any one tax year?
Yes No
26. (a) Does the Applicant Firm have a policy against suing for fees?
Yes No
(b) Does the Applicant Firm refer all collection matters concerning outstanding fees to an independent Collection Agency?
Yes No
(c) During the last 3 years, has the Applicant Firm, or any Predecessor Firm been involved in any disputes with respect to
fees or other compensation, which may be due for professional services rendered?
Yes No
General Practices and Procedures (Provide details to all “No” answers by attachment)
27. Does the Applicant Firm have client project screening procedures?
Yes No
(a) Do these procedures require sign-off by a second partner or relevant special purpose committee prior to accepting a
new engagement?
Yes No
(b) Is the Conflict of Interest avoidance system automated?
Yes No
(c) Does the Conflict of Interest avoidance procedures include:
(i) current and former clients?
Yes No
(ii) clients of Predecessor Firm(s) and merged or acquired firms?
Yes No
(iii) matters or clients that have been declined?
Yes No
28. Indicate what loss prevention tools the Applicant Firm requires members to use.
Engagement Letters are updated:
Annually for all Engagements Annually for Audit and Securities Engagements
Engagement Letters are not used As Engagement Changes Not Updated (Evergreen)
Other: ___________________________________
Second person / partner review of:
Audit / Attest Services All Services
No second person / partner review Taxation Services Other: ___________________________________
29. Does the Applicant Firm have a written policy on Continuing Professional Education (CPE) training, including required
courses and CPE hours per year?
Yes No
30. Number of professionals (and documentation) who have attended an AICPA or other similar quality loss control seminar /
self-study course in the last 3 years.
31. If the Applicant Firm is a sole practitioner, have arrangements been made for another CPA to perform a cold review and
handle client deadlines in the event of an extended absence?
N/A
Yes No
32. Checklists Used. If “None”, so state.
None
AICPA Practitioners Publishing Company Other:
33. Does the Applicant Firm have a calendar system to ensure on-time completion of professional service activities?
Yes No
(a) Is the calendar system automated?
Yes No
(b) Does the calendar system track items, even where no critical deadline is involved?
Yes No
(c) Does the calendar system include a procedure for the verification of the completion of calendared items or the re-
scheduling of events?
Yes No
Carolina Casualty Insurance Company
APL 28500 (rev. 11-07) Page 5 of 6
34. Does the Applicant Firm delegate or refer work outside of the firm?
Yes No
If “Yes”, explain the nature of the work, to whom and percentage of Applicant Firm’s Prior Fiscal Year Gross Revenue via
attachment to this Application.
35. Within the last 3 years, has a peer or on-site quality review under the sponsorship of the AICPA, any state CPA Society, or
any other professional association or organization, been conducted?
Yes No
(a) If “Yes”, indicate the opinion rendered:
Unqualified / Unmodified Qualified / Modified* Adverse*
*If Qualified / Modified or Adverse, provide a copy of the Peer Review Report as well as the Letter of Comments and the
Applicant Firm’s Letter of Response for this review and the Applicant Firm’s prior peer or on-site quality review.
(b) If “No”, and the Applicant Firm provides compilation, review and/or audit services, indicate the anticipated date of
review.
Litigation and Claim Information
36. Has the Applicant Firm, any Predecessor Firm, or any member of the Applicant Firm:
(a) ever had his/her certificate, license, or permit to practice suspended or revoked?
Yes No
(b) ever been subjected to an investigation or disciplinary action by any state board of accountancy, State Society, the
AICPA or any other state or federal regulators?
Yes No
If “Yes”, provide full details.
37. During the last 5 years, has any professional liability claim or suit been made against the Applicant Firm, any Predecessor
Firm, or partner, stockholder or professional staff person?
Yes No
38. Is the Applicant Firm or any partner, stockholder or professional staff person in the Applicant Firm aware of any fact,
circumstance, or situation that might reasonably be expected to result in any professional liability claim or suit against the
Applicant Firm, any Predecessor Firm, or partner, stockholder or professional staff person in the Applicant Firm?
Yes No
IF “YES” TO QUESTIONS 37. OR 38., PROVIDE FULL DETAILS ON THE CLAIM / INCIDENT SUPPLEMENTAL FORM (APL 28610).
IT IS UNDERSTOOD AND AGREED THAT THE INSURER SHALL NOT BE LIABLE TO MAKE ANY PAYMENT FOR LOSS IN CONNECTION
WITH ANY CLAIM MADE AGAINST ANY INSURED BASED UPON, ARISING OUT OF, DIRECTLY OR INDIRECTLY RESULTING FROM OR IN
CONSEQUENCE OF, OR IN ANY WAY INVOLVING ANY LAWSUIT, ADMINISTRATIVE PROCEEDING, WRITTEN DEMAND, FACT,
CIRCUMSTANCE, OR SITUATION SET FORTH OR THAT SHOULD HAVE BEEN SET FORTH IN THE INSURED’S RESPONSE TO QUESTIONS
36., 37., OR 38.
Documents Required (The following information must be submitted with the completed Proposal Form).
• Provide details to all “Yes” answers, when applicable below, or by attachment when additional space is required.
• Completed Supplemental Forms, where appropriate.
Provide Additional Information here
Carolina Casualty Insurance Company
APL 28500 (rev. 11-07) Page 6 of 6
NOTICE TO COLORADO APPLICANTS:
IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY.
PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR
AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO
A POLICY HOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICY HOLDER OR
CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE
COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.
NOTICE TO NEW MEXICO, PENNSYLVANIA APPLICANTS:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY
INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY
MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT
MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND
CIVIL PENALTIES.
NOTICE TO APPLICANTS OF KENTUCKY:
ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY
OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR
THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE
ACT, WHICH IS A CRIME.
NOTICE TO APPLICANTS OF MINNESOTA, NEW JERSEY, OHIO, AND OKLAHOMA:
ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO
INJURE, DEFRAUDS OR DECEIVES ANY INSURER OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF
CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION OR
CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, IS GUILTY OF A FELONY
AND IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO MAINE, MASSACHUSETTS, TENNESSEE, VIRGINIA, AND WASHINGTON APPLICANTS:
IT IS A CRIME TO KNOWINGLY PROVIDE
FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE
COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
NOTICE TO APPLICANTS OF FLORIDA:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY
INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION
IS GUILTY OF A FELONY OF THE THIRD DEGREE.
NOTICE TO ARKANSAS, DISTRICT OF COLUMBIA, LOUISIANA, MARYLAND, AND RHODE ISLAND APPLICANTS:
ANY PERSON WHO
KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE
INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN
PRISON.
NOTICE TO NEW YORK APPLICANTS:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR
OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO,
COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED
FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
Please Read Carefully
The undersigned, acting on behalf of all Insureds, declare that the statements set forth herein are true and correct and that thorough efforts have been
made to obtain sufficient information from each and every Insured proposed for this insurance to facilitate the proper and accurate completion of this
Proposal Form.
The undersigned agree that the particulars and statements contained in the Proposal Form and any material submitted herewith are their representations
and that they are material and are the basis of the insurance contract. The undersigned further agree that the Proposal Form and any material submitted
herewith shall be considered attached to and a part of the Policy. Any material submitted with the Proposal Form shall be maintained on file (either
electronically or paper) with the Insurer and shall be deemed to be attached hereto as if physically attached.
It is further agreed that:
• if any significant change in the condition of the applicant is discovered between the date of this Proposal Form and the Policy inception date,
which would render this Proposal Form inaccurate or incomplete, notice of such change will be reported in writing to the Insurer immediately;
• any Policy, if issued, will be in reliance upon the truth of such representations;
• this Proposal Form has been completed as respects the entire
Applicant Firm;
• the signing of this Proposal Form does not bind the undersigned to purchase the insurance.
Dated Signature of Owner, Partner, Officer or Principal
Title Owner, Partner, Officer or Principal (Print Name)
This Carolina Casualty Insurance Company Proposal Form, including any material submitted herewith, shall be held in strictest confidence.
A POLICY CANNOT BE ISSUED UNLESS THE PROPOSAL FORM IS PROPERLY SIGNED AND DATED.
Please submit this Proposal Form including appropriate documentation to:
Monitor Liability Managers, LLC, 2850 West Golf Road, Suite 800, Rolling Meadows, IL 60008-4039
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Completed 13 December 2020

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