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Accountants Online Indication Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

General Information
Firm Name
Required
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Current Policy Declarations Page Upload
Optional
Last Peer Review Date:
Optional
/ /
Fee Suits Against Clients in past 3 years:
Optional
Gross Annual Revenue for the Firm on an Accrual Basis
Last Fiscal Year:
Optional
Estimate Current Fiscal Year:
Optional
Projected Next Fiscal Year:
Optional
Please indicate the number of personnel for your firm and firm affiliates:
CPA Owners, Partners, & Officers
Optional
Non CPA Owners, Partners & Officers
Optional
Employed CPAs (Other than already included)
Optional
Other Accounting or Tax Professionals
Optional
Consulting Professionals
Optional
Support Staff (All Others)
Optional
Please provide percentages of gross annual revenue derived from the following areas of practice (MUST TOTAL 100%)
Please check the box below each area if engagement letters are used
Business Tax Services
Optional
Engagement Letters Used - Business Tax Services
Optional
Estate Tax Services
Optional
Engagement Letters Used - Estate Tax Services
Optional
Individual Tax Services
Optional
Engagement Letters Used - Individual Tax Services
Optional
Accounting/Bookkeeping
Optional
Engagement Letters Used - Accounting/Bookkeeping
Optional
Compilation
Optional
Engagement Letters Used - Compilation
Optional
Review
Optional
Engagement Letters Used - Review
Optional
Audit: Publicly Held Clients
Optional
Engagement Letters Used - Audit: Publicly Held Client
Optional
Audit: Non-Public Clients
Optional
Engagement Letters Used - Audit: Non-Public Clients
Optional
Agreed Upon Procedures
Optional
Engagement Letters Used - Agreed Upon Procedures
Optional
Projections/Forecasts
Optional
Engagement Letters Used - Projections/Forecasts
Optional
Financial Planning & Investment Advisory Services
Optional
Engagement Letters Used - Financial Planning & Investment Services
Optional
Information Technology
Optional
Engagement Letters Used - Information Technology
Optional
Other Attest/Assurance Services
Optional
Engagement Letters Used - Other Attest/Assurance Services
Optional
Business Planning (Please describe)
Optional
Engagement Letters Used - Business Planning
Optional
Business Valuation
Optional
Engagement Letters Used - Business Valuation
Optional
Litigation Consulting
Optional
Engagement Letters Used - Litigation Consulting
Optional
Non-trustee Fiduciary or Administrative Responsibility-ERISA Pension & Benefit Plans, ESOPS, Insurance Co., Hedge Funds, other Investment Cos.
Optional
Engagement Letters Used - Fiduciary or Administrative Responsibility
Optional
Other Consulting (Please Describe)
Optional
Engagement Letters Used - Other Consulting
Optional
After inquiry of all owners, partners, officers and professionals of the firm and the firm affiliates, within the past 5 years have any past or present personnel:
Been the subject of any regulatory or disciplinary investigation or inquiry (both formal and informal) or have been suspended from practice?
Optional

Charged or plead guilty to, or indicted on a criminal charge
Optional

Become aware of any professional liability claims made against the firm, firm affiliates, their personnel or the firm’s predecessors in business?
Optional

Become aware of any act, omission or fee dispute which might be expected to be the basis of a claim or suit against the firm, firm affiliates, their personnel or the firm’s predecessors in business?
Optional

Been declined canceled or non-renewed for professional liability insurance for any reason other than nonpayment of premium? (This question is not applicable to Missouri residents.)
Optional

*If Yes to any of the above, please provide details on the attached Claim/Incident Supplement
NOTE: This Form is for Estimate Purposes Only. Coverage May Be Bound Only Upon Submission and Acceptance of a Completed New Business Application
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