Secure Web Application
A credit card is required for on line processing and a 6% service fee will be charged
Use the print / mail form and send with your check to avoid a fee

See Rates Below

Applicant - Exact Name  

Address:  Street, City, State
      Zip  
                 Telephone  

Mark all that apply:
  CPA  Enrolled Agent (discount applies*)  Financial Planner
   Attorney  Accountant  Independent Practitioner

Total Number of Owners and Employees (Include part-time)

Number of Offices 

Amount of Coverage Requested:
   $10,000/$20,000  $25.000I$50.000
              $50.000/$100,000  $100,000/$200.000
Are you a member of a tax preparer's association? Yes No
 If yes. please specify which one.
Do you want optional bookkeeping coverage?  Yes No
What percentage of your business is bookkeeping?

Policy includes one year complimentary retroactive coverage.
Do you want to purchase a second year?  Yes No
'Discounts Not Available in Hawaii or Tennessee

Have you sustained any prior losses?   Yes No

Do you currently carry errors and omissions insurance?  Yes No
 Please provide the amount. details and insurance claim status of any prior losses in the comments box below.

Number of years of experience preparing tax returns? 

What types of returns does your firm prepare?Personal Commercial

Have you and your other supervisors attended a continuing education course in the last year?   Yes No

Does your firm subscribe to a tax reporter service type publication?   Yes No
     If so. are they required reading for all preparers?  Yes No

Does your firm regularly check the accuracy of computer software?  Yes No

Does your firm utilize an outside tax preparation service? Yes No
     If yes, does the service hold you harmless for liability that may be incurred as a result of their performance?Yes No

Is there a review of all tax preparation by a supervisor who is not involved in that preparation prior to releasing the return? Yes No

Have you or any member of your firm been subject to a tax preparer's fine(s) or penalized by the Internal Revenue Service, or to disciplinary action by any state board of accountancy, AICPA. or state society? Yes No
    If yes. please list the dates, dollar amounts, and other specifics in Comment Box Below.

Has your firm had a peer review under the sponsorship of the AICPA. a state society. or any other professional association, in the last three (3) years?Yes No
     If yes, were any deficiencies found regarding tax preparation? If so, what steps have been taken to prevent recurrence? Please respond in comment box below.

The applicant hereby warrants that, to the best of his/her/its knowledge, no facts currently exist which could reasonably give rise to a claim against this policy.