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Accountants Professional Liability Estimate

For a preliminary premium estimate, please complete the following form. Our team will assess your information and get back to you within 24 hours. The premium indicated will be an estimate only and is not binding until an underwriter has reviewed a completed application and offers coverage. For guidance in filling out this form, or for a complete application, call 1.800.966.3474 to speak with a McLachlan Kane Insurance Agency representative.
*Required.

Firm Information:

Firm Name^*:

Contact Name^*:

Firm Address:

City:

State:

Zip Code:

Telephone Number^*:

Fax Number:

Email:

This information will not be shared with external partners or vendors.
For CAMICO's privacy policy please go to http://www.camico.com/website/privacy.asp

May CAMICO contact you by e-mail?

Yes No

Currently Insured?

Yes No

Carrier:	Premium:
	$

Prior Acts Date: dd/mm/yyyy

Firm Established: dd/mm/yyyy

Expiration Date: dd/mm/yyyy

Limit of Liability:

Deductable:

Last Annual Gross Revenue:

Current Annual Gross Revenue (est):

Next Annual Gross Revenue (projected):

Percentage of Revenue from the Firm's largest client: %

Staff Count:

Total Number of
Owners/Partners

Number of
Non-Owner CPA's

Number of Non-CPA
Professional Employees

CPA:	Non-CPA:

Full Time:	Part Time:

Full Time:	Part Time:

Estimated Revenue Percentages Derived From Services Offered:

Tax Preparation/Planning

Audit (Indicate Number of SEC Regulated Clients: )

Review and Compilation

Consulting (Please check areas of interest)


Management Advisory	Business Investment
Computer Related Services	Projections/Forecasts
Litigation Support

Special Services (Please check areas of interest)


ERISA	SEC
Fiduciary	Personal Business Mgmt
Financial Plannning	Assurance Services

Other (Please describe briefly)

Number of claims (open or closed within past 3 years):

Total:

%
*Total must equal 100%

Coverage Limit and Deductible:

Check the appropriate box below for limits (higher limits may be available):

$100,000/$1,000 deductible (not available in CA)	$500,000	Other:
$250,000/$2500 deductible	$1,000,000

Check the appropriate box below for deductible (higher or lower deductibles may be available):

$5,000

$7,500

$10,000

$25,000

Other:

Comments: (Not Required)

What's the result of the following arithemetic term 8 + 4?
This prevents automated systems to use this service.