Monarch Insurance Brokers

PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR ACCOUNTANTS/BOOKKEEPERS (Other than Chartered Accountants)

NOTE: Completion of this application form does not bind the Insurer to offer the insurance nor does it obligate the Applicant to purchase the insurance. This application is a declaration and shall form part of any policy wich may be issued.

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NOTE: If the spaced provided to answer any of the questions on this application are insufficient to fully answer the question, please use the remarks section at the end of the form. If it is a continuation from a particular question, please be sure to indicate which question.

1. APPLICANT FIRM:

1.1 Name

Date established

Other trade names presently used

1.2 Address

City

Province

Postal Code

Email

Phone Number

Fax Number

Website

1.3 If the Applicant Firm has any Branch Offices, please provide their Address(es) (if necessary, please use a separate page and send it to Monarch).

1.4 Name previous organization(s); partnership(s) or other business name(s) (if necessary, please use a separate page and send it to Monarch).
a) Disolved

Date Disolved

b) In the course of being disolved

c) Other

2. PROFESSIONAL PRACTICE:

2.1 Give the total number of:

Category of Partner, Associate or Employee	Full-time	Part-time
A. Certified Managment Accountants, Cerified General Accountants, Bookkeepers and Officers
B. CMAs, CGAs, and Bookkeepers - Associates and Employees
C. Other Professional Staff (e.g. Management Consultants, CMAs, CGAs, Lawyers, etc) Please list by each Profession
D. Employees other than CMAs, CGAs or Bookkeepers engaged in client work (e.g.personal assistants, students, clerks, bookkeepers, secretaries)
E. Other Employees (excluding those declared in A, B and C above)
Total

2.2 Has any person shown in question 2.1 A, B, or C ever been the object of disciplinary sanction or suspension? If YES, please append all the relevant details and send to Monarch.
Yes
No

2.3 For the past 5 years, please indicate the date(s) that the Applicant's Firm was the subject of a Practice Review by a Provincial Institute of either CMA, CGA or another regulatory authority.

Never Reviewed	Date	Date	Date	Date

2.4
a) Indicate the Applicant Firm's Annual Gross Revenue from all sources, for the last three (3) fiscal years:
Period:   Gross Revenues: $
Period:   Gross Revenues: $
Period:   Gross Revenues: $

b) For the last fiscal year indicate the Applicant Firm's Gross Revenues emanating from the three most important clients (individual clients or group of clients under common control):
Gross Revenues: 1st $    2nd $    3rd $

2.5 Indicate the approximate percentage of the Applicant Firm's Gross Revenues for each service offered during the Applicant Firm's last fiscal year:

Category of Service	Percentage of Gross Revenues
Audit Engagements (Auditor's Reports) for Public and/or Privately Held Entities
Tax Return Preparation for Corporation and/or individuals
Tax and/or Estate Planning
Trustee in Bankruptcy and/or Receivership
Review Engagement and/or other Financial Statement Preparation
Bookkeeping
Management, Strategic Planning and/or Business Reorganization Consulting
Computer Consulting
Investment Consulting
Merger and/or Acquisition Consulting and/or Business Evaluation relating to Acquisitions by a Client
Property and/or Asset Management for Others
Direct Business Management for Others ( on a separate page explain who gave the Applicant Firm this mandate, the length of the mandate and the name(s) and nature of the business(es) managed and send to Monarch)
Trust Fund Management
Other Services (Specify)
Total:

2.6 Computer related services:
Does the Applicant Firm provide Computer Related Services? If YES, under what name does the Applicant Firm provide such services:
Yes
No

2.7 Please indicate the approximate percentage of income for each service offered:

Category of Service	Percentage of Gross Revenues
Hardware and/or Software Consulting
Sale of Hardware and/or Software
Programming Services
Data Processing
Other Services (Specify)
Total:	100%

2.8 Does the Applicant Firm or any member of the Applicant Firm:
a) have an ownership interest in any client to whom the Applicant Firm provides professional services? If YES, please append full details on a separate page, showing the percentage of ownership interest held and the gross fees derived from the professional services provided by the Applicant Firm to this client and send to Monarch.
Yes
No

b) provide professional services to an outside firm or company that also employs the Applicant Firm or a member of the Applicant Firm? If YES, please append full details on a separate page and send to Monarch.
Yes
No

2.9 Does the Applicant Firm provide professional services to clients who are domiciled outside of Canada? If YES, please append details on a separate page of where those clients are domiciled, the type of services rendered to them by the Applicant Firm and the percentage of Gross Revenues that these services have represented during each of the past three years and send to Monarch.
Yes
No

2.10 Does the Applicant Firm subcontract out work to other professionals? If YES, describe the type of work and give the annual amount sub-contracted for the last three fiscal years:
Yes
No

2.11 If the Applicant Firm responded yes to Question 2.10, does the Applicant Firm require the its sub-contractors carry their own Professional Liability Insurance? If NO, why not?
Yes
No

2.12 In the past five years, has the Applicant Firm or any member of the Applicant Firm ever recommended or, is the Applicant Firm or any member of the Applicant Firm considering recommending, to clients an investment in any business venture (other than those quoted on the stock market) in which the Applicant Firm or any member of the Applicant Firm has a financial interest? If YES, please provide the details on a separate page, including the ownership interest held by the Applicant Firm or member of the Applicant Firm and the fees charged to the client (if any) in relation to this investment and send to Monarch.
Yes
No

2.13 In the past five years, has the Applicant Firm or any member of the Applicant Firm received, or will the Applicant Firm receive in the future, a direct or indirect compensation (e.g. finder's fees, commissions or other consideration) for making the recommendations in respect of an investment opportunity to a client? If YES, please provide the details, on a separate page, of the investment and the nature of the compensation received for each such transaction and send to Monarch.
Yes
No

2.14 Does the Applicant Firm or any member of the Applicant Firm act as an Accountant or Financial Advisor to any Limited Partnership? If YES, please specify, on a separate page, the names, details of services and fees charged.
Yes
No

3. PRIOR INSURANCE AND CLAIMS:

3.1 During the last five years, has the Applicant Firm carried Professional Liability (Error and Omissions) Insurance? If YES, please complete the following for all previous insurance.
Yes
No

NAME OF INSURER	POLICY NUMBER	POLICY PERIOD		LIMITS OF LIABILITY	DEDUCTIBLE	ANNUAL PREMIUM
NAME OF INSURER	POLICY NUMBER	FROM	TO	LIMITS OF LIABILITY	DEDUCTIBLE	ANNUAL PREMIUM

3.2 During the past five years has any Insurer ever cancelled, declined or refused to renew the Applicant Firm's or any previous organization's or partnership's Professional Liability (Errors and Omissions) Insurance? If YES, state in each case, the name of the Insurer and give the reason(s):
Yes
No

Insurer	Reasons

3.3 After making an inquiry of all members of the Applicant Firm, including predecessors in business and former staff, either individually or otherwise, has anyone, in the past five years, ever been the subject of a claim in respect of the liabilities to be covered by the proposed insurance? If YES, please append full details, the date and amount of the claim(s) on a separate page and send to Monarch.
Yes
No

3.4 After making an inquiry of all members of the Applicant Firm, including predecessors in business and former staff, either individually or otherwise, has anyone, in the past five years, ever given notice of a possible claim to an Insurer in respect of the liabilities to be covered by the proposed insurance? If YES, please append full details, the date and amount of the claim(s) on a separate page and send to Monarch.
Yes
No

3.5 After making an inquiry of all members of the Applicant Firm, including predecessors in business and former staff, either individually or otherwise, has anyone, in the past five years, is anyone aware of any act or circumstance which could reasionably be expected to be the basis of a future claim in respect of the liabilities to be covered by the proposed insurance? If YES, please append full details, the date and amount of the potential claim(s) on a separate page and send to Monarch.
Yes
No

For the purpose of this Application Form, the word claim, as used in Questions 3.3, 3.4 and 3.5 means:

a verbal or written demand for money damages from a third party;
a verbal or written allegation suggesting that the Applicant Firm or a member of the Applicant Firm including predecessors in business and former staff, may have committed an error, omission or negligent act in respect of professional services provided to a third party; and or
a fact or circumstance arising out of professional services that the Applicant Firm or a member of the Applicant Firm, which could reasonably be foreseen to give rise to a future claim for money damages.

FOR EACH ANSWEROF "YES" TO QUESTIONS 3.3, 3.4 OR 3.5, ON A SEPERATE PAGE, PLEASE PROVIDE THE DATES, CIRCUMSTANCES SURROUNDING THE MATTER CONTEMPLATED BY AN AFFIRMATIVE RESPONSE, TO THOSE QUESTIONS, THE NAMES OF THE CLAIMANT, QUANTUM OF DAMAGES DEMANDED AND THE CURRENT STATUS OF EACH MATTER (CONTINUING, CLOSE, ETC), AND SEND TO MONARCH.

4. COVERAGE AND DEDUCTIBLE (SUBJECT TO THE INSURER'S APPROVAL):

4.1 Limits of liability:
$250,000
$500,000
$1,000,000
$2,000,000
Other:
$

4.2 Deductible amount each loss:
$1,000
$2,500
$5,000
$10,000
Other:

4.3 Suggested effective date of the insurance contract:

REMARKS (optional - or use to complete questions above)