# Surcharge Schedule

| Named Insured | International Business Machines Corporation |
|---------------|--------------------------------------------|
| Policy Symbol  | HDO                                        |
| Policy Number | G72490587                                  |
| Policy Period | 05/21/2021 to 05/21/2022                   |
| Issued By     | ACE American Insurance Company              |

The following surcharge(s) have been applied at inception of this policy:

| State       | Name of Surcharge                          | Amount |
|-------------|-------------------------------------------|--------|
| KY          | KY Public Service Surcharge                | $6.00  |
| NJ          | NJ Property Liability Insurance Guarantee Association | $7.00  |

Surcharges will be adjusted at audit and concurrent with any other applicable premium adjustment. The rates used to adjust the surcharges are set by the states. The formulae for the adjustment bases used to adjust the surcharges are also set by the states.

ALL-22421 (10/11)
Page 1 of 1