Firm Name: _________________________________________________ Address: _________________________________________________ City: _________________________ State: ____ Zip: __________ Web Address: __________________________________Phone Number: __________________________________ Contact Name: __________________________________ Email Address: __________________________________

Number of Claims in the last 5 years: ____(1) Open ___ Closed ___ Amount Paid: __________(2) Open ___ Closed ___ Amount Paid: __________

Firm Type: ____________Year Established: ____________

Annual Gross Revenues: ____________

Does your firm.......1. act as an officer, director, trustee, partner, employee, or have any equity interest in any client?.....2. utilize engagement and non-engagement letters?............................................................................ 3. file suits for the collection of fees? If “yes”, how many in the last two years? ____ .........................4. maintain a docket system that employs at least two independent date controls?............................. 5. maintain a conflict of interest avoidance system?............................................................................. 6. have any lawyer with disbarments, disciplinary actions, bar complaints, or suspensions?.. ...........7. derive more than 50% of gross annual billings from any one client?................................................ 8. share office space with any other firm or lawyers?...........................................................................9. have any predecessor firms?............................................................................................................

Current Carrier: _________________________Expiration Date: _________________________

Limits of Liability: _________________________Deductible: _________________________

Prior Acts Date: _________________________Premium: _________________________

Signature:Print Name:

Date: IND040512PICReturn to: Lawyers@Jaymes.pro

Yes ___ No ___Yes ___ No ___Yes ___ No ___Yes ___ No ___Yes ___ No ___Yes ___ No ___Yes ___ No ___Yes ___ No ___Yes ___ No ___

Number of Lawyers: _____ Number of Non-Lawyer Staff: _____

Attorney Name Date of Hire Hours/Week(1) __________________________________ _________ ______(2) __________________________________ _________ ______(3) __________________________________ _________ ______(4) __________________________________ _________ ______(5) __________________________________ _________ ______

LAWYERS PROFESSIONAL LIABILITY INSURANCE

INSURANCE for

LAWYERS

www.Jaymes.pro

JAYMES & JAYMES Inc. CA License #0763401

____ Administrative Law____ Admiralty / Maritime____ Anti-Trust / Trade Relations____ Arbitration / Mediation____ Banking / Financial Institutions____ Bankruptcy____ Civil Rights / Discrimination____ Class Action / Mass Tort Law____ Collections / Repossessions____ Commercial Litigation____ Commercial Transactions____ Corporation Formation / Alteration____ Criminal Law____ Domestic Relations____ Entertainment / Sports____ Environmental____ Estate / Probate / Trust____ Government / Municipal (Not Bonds)____ Immigration / Naturalization____ Insurance Defense____ Intellectual Property Counseling____ Intellectual Property Infringement / Opinions____ Intellectual Property Litigation____ Intellectual Property Services - Other____ Other

____ Intellectual Property Trademark Registration____ Intellectual Property Trademark Search____ International / Foreign Law____ Labor - Labor Representation____ Labor - Management Representation____ Mergers / Acquisitions____ Oil / Gas / Mining____ Patent /Copyright / Trademark Licensing____ Patent Prosecution - Domestic or Foreign____ Patent Searches - Domestic or Foreign____ Pension & Employee Benefits____ Personal BI/PD Defense____ Personal BI/PD Plaintiff____ Real Estate - Commercial____ Real Estate - HOA / COA Representation____ Real Estate - Land Use / Zoning____ Real Estate - Loan Modifications____ Real Estate - Residential____ Real Estate - Title Examination____ Securities____ Tax Opinions____ Tax Return Preparation____ Workers Compensation - Defense____ Workers Compensation - Plaintiff

100% TOTAL