# ACE GROUP SPECIALTY CLAIMS LOSS NOTIFICATION FORM

**Today's Date:**

**Notice of:** (check all that apply)
- First-Party Claim
- Potential Claim
- Third-Party Claim
- Litigation Initiated
- Other

**Insured's Name & Contact Information**
- **Company Name:** International Business Machines Corporation
- **Address:** One New Orchard Road (Mail Drop 109) Armonk, New York 10504
- **Phone Number:** [Not provided]

**Broker/Agent's Name & Contact Information**
- **Company Name:** AON RISK SERVICES NORTHEAST INC
- **Address:** 199 WATER STREET NEW YORK, New York 10038
- **Phone Number:** [Not provided]

**Policy Information**
- **Policy Number:** XOO G27983212 001
- **Policy Period:** 05/21/2016 - 05/21/2017
- **Limits of Liability:** $50,000,000 per $50,000,000 agg Self-Insured Retention/Deductible: $N/A

**Loss Information**
- **Date of Incident/Claim:** [Not provided]
- **Location:** [Not provided]
- **Claimant Name/Address:** [Not provided]
- **Description of Loss:** [Not provided]

**Please list all attached or enclosed documentation:** [Not provided] (check if none provided)

**Name of Person Completing This Form:** [Not provided]
**Signature:** [Not provided]

**FORWARD BY FAX, MAIL OR E-MAIL TO:**
- ACE Excess
- P.O. Box 5103
- Scranton, PA 18505-0510
- Fax No.: (866)635-5687
- ACEClaimsFirstNotice@acegroup.com

XS-28500a (08/13)
© 2013
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