Name of Business (Exact Name) *

Address (include any branch locations) *

City *     State * Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming    Zip *

Daytime Phone # *      Fax Number     

Email Address *

Member # / Agency Customer ID (if applicable)

Check all that apply:   CPA    Financial Planner    Accountant    Attorney    Independent Practitioner

                                        Enrolled Agent (Discount applies; Discount not available in Hawaii or Tennessee)

Total Number of Owners & Employees (include part-time) *      Number of Offices *  

Amount of coverage requested: *  $10,000/$20,000   $25,000/$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

1. Have you sustained any prior losses? * Yes    No     Do you currently carry errors & omissions insurance? * Yes    No

Please provide the amount, details, and insurance claim status of any prior losses.  (Send in separate email if necessary.)

2. Number of years of experience preparing tax returns? *  

3. What types of returns does your firm prepare?    Personal    Commercial

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

5. Does your firm subscribe to a tax reporter service or similar publication? * Yes    No

    If so, are they required reading for all preparers?   Yes    No

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

7. 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

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

9. Have you or any member of your firm been subject to a tax preparer's fine(s) or penalty levied by the Internal Revenue Service, or to disciplinary action by any state board or accountancy, AICPA, or state society? * Yes    No

    If yes, please list the dates, dollar amounts, and other specifics. (Send in separate email if necessary.)
   

10. 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?  Yes    No

    If so, what steps have been taken to prevent recurrence? (Send in separate email if necessary.)
   

11.  All information provided to Surety by the Applicant is true, accurate and complete.  An Authorized Representative shall execute this Application by typing his or her signature below and providing the information requested.  The Surety reserves all rights and legal duties associated with this Application and any and all bonds issued as a result.

    Officer Name: *  

    Official Title: *  

    Date (mm/dd/yyyy) *  

For your protection, California law requires the following to appear on this form:  Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.