# ACE GROUP SPECIALTY CLAIMS LOSS NOTIFICATION FORM

**Today's Date:**

**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 Mail Drop 109, Armonk, NY 10504
- **Phone Number:** _______________________
- **Point of Contact:** _______________________

**Broker/Agent's Name & Contact Information**
- **Company Name:** AON Risk Services
- **Address:** 199 Water Street, 30th Floor, New York, NY 10038
- **Phone Number:** _______________________
- **Point of Contact:** Nick Moore

**Policy Information**
- **Policy Number:** XOO G25915951
- **Limits of Liability:** $50,000,000 per $50,000,000 agg
- **Self-Insured Retention/Deductible:** 0.00
- **Policy Period:** 05/21/2012 - 05/21/2013

**Loss Information**
- **Date of Incident/Claim:** _______________________
- **Location:** _______________________
- **Claimant Name/Address:** _______________________
- **Description of Loss:** _______________________

**Please list all attached or enclosed documentation:** ☐ (check if none provided)

**Name of Person Completing This Form:** _______________________
**Signature:** _______________________

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XS-28500 (10/09) © 2009

**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.

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