# Allianz Global Risks US Insurance Company

## FORMS AND ENDORSEMENT LIST

**NAMED INSURED:** International Business Machines Corporation  
**POLICY NUMBER:** USL00197722  
**EFFECTIVE DATE:** 5/21/2022  

The following policy forms and endorsements have been attached to and made a part of the policy at inception.

| FORM NAME | FORM NUMBER | EDITION DATE |
|-----------|-------------|--------------|
| Excess Liability Following Form Short Excess Form Declarations | AGRL XS ASF 1000 10 20 | 10/2020 |
| Fraud Statement | 141874 12 21 | 12/2021 |
| Policyholder Notice - All States (Claims Reporting Information) | AGR-IL 8001 (12-19) | 12/2019 |
| Policyholder Notice - OFAC | AGR-IL 8003 (01-05) | 01/2005 |
| Following Form Excess Liability Short Excess Form | AGRL XS ASF 2000 10 20 | 10/2020 |
| Schedule of Excess Policy(ies) | AGRL XS ASF 1001 10 20 | 10/2020 |
| Nuclear Energy Liability Exclusion Endorsement (Broad Form) | AGRL-XS 5124 (02-16) | 02/2016 |
| Asbestos Exclusion | AGRL-XS 5125 (02-16) | 02/2016 |
| War Exclusion | AGRL-XS 5127 (02-16) | 02/2016 |
| Cap on Losses from Certified Acts of Terrorism | AGR-XS 5008 (01-15) | 01/2015 |
| Non Following Form Endorsement | AGRL XS ASF 5001 10 20 | 10/2020 |
| Economic or Trade Sanctions Endorsement | AGRL-XS 5120 (02-16) | 02/2016 |
| New York Amendatory | AGRL IL NY01 08 19 | 08/2019 |
| Important Notice New York Free Trade Zone Filing Exemption and Class Code Disclosure | AGRL IL 8NY01 01 21 | 01/2021 |
| Definition of Pollutant(s) (Indiana) Endorsement | M-AGRl XS ASF 5002 01 21 | 01/2021 |

AGR-DS 1002 (11-03)