# Casualty Claims Department Claim Report Form (MCL-1678-A)

## Header
- **Claim Ref:** P G Wallace
- **Date Given to Service Unit:** 
- **Action:** Create new file
- **W & M Claim:** 32462
- **Pending Date:**
- **Client:** IBM, JH
- **Client Type:** International Business Machines Corp.
- **Claim Title (Optional):** Clean Room Chemical Litigation
- **Claim Type (P/E):** P/E
- **Date of Loss:** 1979 - April 7, 2000
- **Policy Periods Exposed:** 
- **Date Claim Made:** 
- **Location:** California
- **Loss Code:** 15
- **Type:** Product Liability
- **Ad Damnum (Actual):** $500,000,000
- **Claimant(s):**
  - Batista, Aniceto (Deceased)
  - Haq, Khaled

## Primary Policy Information
- **Primary Policy No.:**
- **Policy Period:**
- **Policy Limits:**
- **Primary Carrier:**
- **Street Address:**
- **City:**
- **State:**
- **Zip Code:**

## Special Instructions
- **Dennis Williams:**
  - Please notify all excess insurance policy years: 1979 - April 7, 2000 All Layers
  - Send copy of demand letter of 4/12/00 to Lummane & Compluit
- **Manual List of Excess Insurance Schedule & Mailing List**

## CC
- **Macey Siskind, Esquire**
  - **Address:** 44 South Broadway, White Plains, NY 10601
- **A. Michael Corwin, Esquire**
  - **Address:** 599 Lexington Avenue, New York, New York 10022

## Send the Following Form to Carriers
- **First Notice Primary-Non Suit (FN1)**
- **First Notice Primary-Suit (FN2)**
- **First Notice Excess (FN3)**
- **Closing Notice w/att (CN1)**
- **Closing Notice w/o att (CN2)**
- **Additional Correspondence (AC1)**
- **Follow-up Acknowledgement (ACK)**
- **Notice of Circumstance (INC)**
- **Incident-to-Claim (ITC)**

## Claim Input By:
- **No. of Copies Needed:**
- **MM 007000**