Affinity Insurance Agency, Inc.
Accountants Professional Liability
 
TO: Affinity Insurance Agency
3950 Cobb Parkway, Suite 707
Acworth, GA 30101 		Tel. 770-974-5502
Fax 770-974-5359
Just give us a few facts about your firm and we can provide you with a premium estimate. We will need to see a fully completed application before we can send you a firm quote, but this should be enough information for a reasonably good estimate.
Contact Person:
Firm:
Phone:
Email: 		Address:
City: State: Zip:
Fax:
Website:
Consent Form: By entering my firm name, fax number (s), and my name above, I am authorized to and consent to the firm receiving faxes sent by or on behalf of Affinity Insurance Agency, Inc.
1.-Provide the number of accountants and their years with your firm based upon their date of employment.
Number of Accountants:
7 + years
6 + years
5 + years
4 + years
 3 + years
2 + years
1 + years
< 1 year
# of non-accountant
Staff:

Date firm Founded:
2.In the last 3 years, how many of your firm attended a loss control seminar?

3A. Percentages of gross income received from the following activities for the past year. . Total must equal 100%
Audit, publicly Traded Co.’s %
Audit, Private Co.’s %
Audit, Non-profit %
Audit, Gov’t entities %
Other Audit /Assurance DESCRIBE %
Review %
Compilation %
Bookkeeping
Forecasts/Projections %
Personal Financial Planning DESCRIBE %
 Individual Tax %
Business Tax %
Estate Tax %
Consulting Services DESCRIBE %
Fiduciary Services %
Litigation Support
Securities Activities DESCRIBE %
Business Valuations %
Business Planning DESCRIBE %
Other Services DESCRIBE %
Total must equal 100%
 
If activity is followed by Describe, please provide an explanation:

3B.-What were your gross revenues last 12 months?
Projected gross revenues for next 12 months?

4.-Current Malpractice Insurer:
Retroactive Date of Policy:
Current Deductible: 		Expiration Date of Policy:
Current Limits of Liability:
Current Premium:
5.- Limits of Liability Desired: Deductible Desired:

6.- Have you had or reported any claims within the last five (5) years? Yes No

If yes how many?: One Two Three Four

If yes, Please give a brief description of the claim including date claim(s) reported, amount  paid including defense expenses (if closed) and reserve amount (if open)

7.- Has the firm uses engagement letters? YES NO 
 8.- 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


3950 Cobb Parkway, Suite 707 Acworth, GA 30101
Tele. (770) 974-5502 * Fax (770) 974-5359
September 2007