# Surcharge Schedule

| Named Insured | International Business Machines Corporation |
|---------------|--------------------------------------------|
| Endorsement Number | 5 |
| Policy Symbol | HDO |
| Policy Number | G71445653 |
| Policy Period | 05/21/2020 to 05/21/2021 |
| Effective Date of Endorsement | - |
| 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.

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

| State | Name of Surcharge | Amount |
|-------|------------------|--------|
| KY    | Kentucky Domestic, Foreign and Alien Insurers Surcharge | $8.00 |
| NJ    | NJ Property Liability Insurance Guarantee Association | $13.00 |
| WV    | WV Premium Surcharge | $5.00 |

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.