# ACE USA Specialty Claims Loss Notification Form

**Today's Date:** 20 May 2009

**Notice of:**
- First-Party Claim
- Potential Claim
- Third-Party Claim
- Litigation Initiated
- Other

**Insured's Name & Contact Information**
- **Company Name:** International Business Machines Corporation
- **Address:** One North Castle Drive, CHQ Global Risk & Insurance Management, Mail Drop 222, Armonk NY 10504
- **Point of Contact:** [Not specified]
- **Phone Number:** [Not specified]

**Broker/Agent's Name & Contact Information**
- **Company Name:** AON RISK SERVICES NORTHEAST INC.
- **Address:** 199 WATER STREET, 30TH FLOOR, NEW YORK NY 10038
- **Point of Contact:** Nick Moore
- **Phone Number:** [Not specified]

**Policy Information**
- **Policy Number:** XOO G24895944
- **Policy Period:** 05/21/2009 - 05/21/2010
- **Limits of Liability:** 50,000,000 per 50,000,000 agg
- **Self-Insured Retention/Deductible:** 0.00

**Loss Information**
- **Date of Incident/Claim:** [Not specified]
- **Location:** [Not specified]
- **Claimant Name/Address:** [Not specified]
- **Description of Loss:** [Not specified]

**Please list all attached or enclosed documentation:** [Not specified]

**Name of Person Completing This Form:** [Not specified]
**Signature:** [Not specified]

**Form Version:** May 2007

**CLASS CODE:** 2-13000
**NOTICE:** THESE POLICY FORMS AND THE APPLICABLE RATES ARE EXEMPT FROM THE FILING REQUIREMENTS OF THE NEW YORK STATE INSURANCE DEPARTMENT. HOWEVER SUCH FORMS AND RATES MUST MEET THE MINIMUM STANDARDS OF THE NEW YORK INSURANCE LAW AND REGULATIONS.

**Forward by Fax, Mail or E-mail to:**
- **ACE USA Specialty Claims**
- **140 Broadway, 40th Floor**
- **New York, NY 10005**
- **Fax No.: (646) 458 - 5933**
- **CasualtyRiskExcessFirstNotice@ace-ina.com**