**Insurance Claim Form**

**Company Name:** National Union Fire Insurance Company

**Insured's Name and Address:**
- **Name:** International Business Machines (IBM)
- **Address:** Johnson & Higgins, New York, NY

**Producer's Name and Address:**
- **Name:** Johnson & Higgins
- **Address:** New York, NY

**Branch Claim Office:**
- **Office:** Chicago

**Date of Accident:**
- **Year:** 1979
- **Month:** October
- **Day:** 20
- **Time:** 8:00 AM

**Adjuster's Name and Location:**
- **Name:** [Not specified]
- **Location:** [Not specified]

**Driver's Information:**
- **Name:** [Not specified]
- **Age:** [Not specified]
- **Description of Vehicle:** [Not specified]
- **Year:** [Not specified]
- **Trade Name:** [Not specified]
- **Type of Bodily Injury:** [Not specified]
- **Serial Number:** [Not specified]

**Auto B.I. (Mass. Stat.)**
- **U.M.I.:** [Not specified]
- **Med. Pay:** [Not specified]
- **Products Liability:** [Not specified]
- **Gen'l P.D.:** [Not specified]
- **Ded.:** [Not specified]
- **Single Limit:** [Not specified]

**Auto P.D.**
- **Comp.:** [Not specified]
- **Loss of Use:** [Not specified]
- **Coll.:** [Not specified]
- **B.F.E.:** [Not specified]
- **C.O.:** [Not specified]
- **F.D.:** [Not specified]
- **Theft:** [Not specified]
- **C.A.C.:** [Not specified]
- **Towing:** [Not specified]
- **Garage Keeper's Liability:** [Not specified]
- **Riot:** [Not specified]
- **Ded.:** [Not specified]
- **Coll.:** [Not specified]

**Description of Risk - Mass Endorsements:**
- **Umbrella Liability:** $8,000,000/$18,000,000 E/O $2,000,000/$2,000,000 E/O Primary Layer "A"

**Claimant or Loss Payee:**
- **Name:** Linda Nabuffe

**Injury:**
- **Symptoms:** [Not specified]
- **Ref. Date:** [Not specified]
- **Max. Class Sec. Profit Unit:** [Not specified]
- **Age:** [Not specified]
- **Age No.:** [Not specified]
- **Amount or Loss Date:** [Not specified]

**Statistical Code Area:**
- [Grid with various codes and numbers]

**Reinsurance Company:**
- [Not specified]

**Amount:**
- [Not specified]

**Underwriting Copy**