Oswald Accountants Professional Liability Application

Contact Information

First Name

Contact Name

Firm Address

City State Zip

Phone #

Fax #

Contact Email

Website/URL

Firm Information

Are you or is someone at the firm an OSCPA member?

Date Firm Established

Most Recent Annual Revenue

Projected Annual Revenue

Total Professional Staff

Total Support Staff

Total Staff

In the last 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?

Has any member of the firm provided services or acted as a director/officer/committee member for any financial Institution?

Current Coverage

Current Coverage (If yes, please provide the below information)

Limits

Deductible

Retrodated

Premium

Areas of Practice

Please indicate below the percentage of gross income generated from each area of practice in the past year.

Audit of Publicly Traded Entities

Bookeeping

Audit (not-for-profit)

Trustee Services

Audit (all-other)

Personal Financial Planning

Review

M.A.S.*

Compilation

Information Technology*

Taxation (estate)

Business Valuation

Taxation (individual under 10MM)

Consulting*

Taxation (individual over 10MM)

SEC / Sarbanes Oxley Services*

Taxation (business)

Other Services*

*Please describe in detail

Claims History Within The Last 5 Years

Date Claim(s) Reported/Amount Paid, including Defense Expenses (if closed) & Reserve Amount (if open)

Terms and Conditions *

By submitting this indication sheet, I hereby acknowledge that this indication sheet is intended for information collection purposes only, and submission does not guarantee that coverage will be placed for my firm and does not obligate my firm to purchase coverage. By submitting this indication sheet, I further agree that Oswald Companies shall be the exclusive Broker of Record (BOR) with respect to any/all quotes I may receive based upon this application.

I agree to the terms and conditions

Please contact Kim Ferenchak with any questions (p. 216-367-4942; kferenchak@oswaldcompanies.com).