# Claims Loss Notification Form

## CHUBB

## FORWARD BY FAX, MAIL OR E-MAIL TO:
Chubb Excess Casualty  
P.O. Box 5103  
Scranton, PA 18505-0510  
Fax No.: (866) 635-5687  
ChubbClaimsFirstNotice@Chubb.com

## Notice of: (check all that apply)
- [ ] First-Party Claim
- [ ] Potential Claim
- [ ] Third-Party Claim
- [ ] Litigation Initiated
- [ ] Other

## Insured's Name & Contact Information
- **Company Name:** International Business Machines Corporation  
- **Address:** One New Orchard Road, Armonk, New York 10504  
- **Phone Number:**  
- **Point of Contact:**  

## Broker/Agent's Name & Contact Information
- **Company Name:** AON RISK SERVICES NORTHEAST INC  
- **Address:** 1 LIBERTY PLAZA-REGUS NEW YORK, New York 10006  
- **Phone Number:**  
- **Point of Contact:**  

## Policy Information
- **Policy Number:** XEU G27983212 006  
- **Point Period:** 05/21/2021 - 05/21/2022  
- **Limits of Liability:** 25,000,000 Per 25,000,000 agg.  
- **Self Insured Retention/Deductible:** N/A  

## Loss Information
- **Date of Incident/claim:**  
- **Location:**  
- **Claimant Name/Address:**  
- **Description of Loss:**  

XSE-52231 (03/19)

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