# CLAIMS LOSS
NOTIFICATION FORM

## Forward by Fax, Mail or E-mail to:
- Chubb Excess Casualty
  - P.O. Box 5103
  - Scranton, PA 18505-0510
  - Fax No.: (866) 635-5687
  - ChubbClaimsFirstNotice@Chubb.com

### 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 1 Armonk, New York 10504
- **Phone Number:** [Not provided]
- **Point of Contact:** [Not provided]

## Broker/Agent's Name & Contact Information
- **Company Name:** AON RISK SERVICES NORTHEAST INC
- **Address:** 1 LIBERTY PLAZA-REGUS NEW YORK, New York 10006
- **Phone Number:** [Not provided]
- **Point of Contact:** [Not provided]

## Policy Information
- **Policy Number:** XEU G27983212 005
- **Point Period:** 05/21/2020 - 05/21/2021
- **Limits of Liability:** 25,000,000 Per 25,000,000 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]

XSE-52231 (03/19)
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