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Errors & Omissions Application Form

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Company name
Name of insured
Company address
Company website
Is the applicant or employees a certified public accountant?
Limit of Insurance
Deductible
Describe the professional activities of your firm and years of experience
Is your firm involved in any other business or profession other than described above?
If Yes, please describe
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Do you work with individuals with assets over $1,000,000?
Applicant is a/an
Does the applicant ever function in a dual intermediary agent function?
Historical gross revenues (most recent year first)

Year

Year

Year

Year

Amount

Amount

Amount

Amount

List the percentage of revenues from the following transaction types

Commission (%)

Flat Fee (%)

Other (%)

Average / Maximum value of transaction

Average

Maximum

Number of
independent contractors

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Gross revenue by type of transaction

Transactions
(Past Year)

Revenue
(Past Year)

Revenue
(Current Year)

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(Current Year)

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Revenue
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Does the applicant prepare a broker's reconstruction of financial statements?
Does the applicant conduct any business valuation or due diligence on behalf of the buyer or seller?
Does applicant provide written recommendations that each party retain an attorney and accountant for purpose of performing due diligence review, including an evaluation of income, expense, and feasibility of the business opportunity represented?

Number of partners, principals, officers, and professional employees engaged in providing professional services to clients

Number of non-professional service employees

Is the applicant firm controlled, owned or associated with any other firm, corporation or company?
If Yes, please describe the relationship
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Please provide the following information on key employees, principals, partners
Full name of key employee
Professional qualifications
How long in practice?
Date qualified
How long partner/principal?
What professional association does the applicant belong to?
Please list four largest deals in the past three years
Project / Deal / Client Name
Nature of the services
Revenue obtained
Does the applicant use a written contract with the client?
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What percent of applicant’s business involves subcontracting of work to others?

Does the applicant have similar insurance in place?
(If YES, provide policy with application)
Has the applicant had any claims on insurance in place?

How many claims in last five years?

Describe any claims or disciplinary actions by authorities as a result of professional activities
Direct phone number of applicant
Direct email of applicant
Name of applicant
Date
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