# Kentucky Local Government Premium Tax Schedule

| Named Insured | International Business Machines Corporation |
|---------------|--------------------------------------------|
| Endorsement Number | 5 |

| Policy Symbol | Policy Number | Policy Period | Effective Date of Endorsement |
|--------------|---------------|---------------|-------------------------------|
| HDO          | G48898919     | 05/21/2024 to 05/21/2025 |                           |

| Issued By (Name of Insurance Company) | ACE American Insurance Company |
|---------------------------------------|--------------------------------|

Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.

**THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.**

The premium shown on the Declarations includes the total tax amount for the Kentucky Local Government Premium Tax which is the sum of the tax amounts for each taxing jurisdiction shown below. Each tax amount includes the tax prescribed by the State of Kentucky in accordance with KRS 91A.080 and a collection fee pursuant to KRS. 91A.080(4) and 806 KAR. 2:090.

| Taxing Jurisdiction | Tax Amount |
|---------------------|------------|
| LAKESIDE PARK        | $63.00     |

Authorized Representative

ALL-32677a (04/12)

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