As of the effective date of coverage, the undersigned (hereinafter called the "Subscriber") as a firm becoming a Subscriber, hereby subscribes to, and agrees to be bound by the terms of, (i) the American Institute of Certified Public Accountants Group Insurance Trust (the "Trust") – which trust is maintained pursuant to an agreement (the "Agreement") between the American Institute of Certified Public Accountants (hereinafter called the "Institute") and the financial institute then serving as trustee thereunder (the "Trustee") and (ii) the Plan document. (The current Trustee is The Bank of New York Mellon.) Participation is requested in the plan of insurance (the "Plan") as indicated. Insurance is to become effective according to the Plan, and the date is to be confirmed by the Plan Agent, acting for the Trustee, as soon as possible. The conditions appearing below are hereby agreed to by the Subscriber.

It is understood that the Agreement, among other things, provides that: (1) Subscribers shall make contributions to the Trustee in such amounts as may be required for the purpose of providing and maintaining insurance in accordance with the plans of insurance under the Trust and for the purpose of administration; (2) Subscribers shall furnish to the Trustee any information required in connection with the administration of the Trust and the plans of insurance thereunder; and (3) the plans may be modified from time to time in any respect as may be directed by the Board of Directors of the Institute.

It is further understood that: (1) if the Plan Agent, acting for the Trustee, shall determine that the Subscriber is eligible to participate, the Plan Agent shall promptly confirm the effective date; (2) the insurance of an eligible individual shall, as to its effective date and in every other respect, be governed by the provisions of the contracts held and administered by the Trustee pursuant to the Plan (as well as by the terms of the Plan document); (3) if the Subscriber is determined not to be eligible to participate, this Subscription Form shall be considered null and void and the Trustee shall refund the remitting Subscriber any payment enclosed herewith; and (4) insurance is to become effective only upon acceptance by the underwriting company, and the Plan Agent, acting for the Trustee, will inform the Subscriber requesting insurance regarding the effective date of coverage.