# INITIAL STATEMENT OF ADJUSTMENT

**Insured's Name:** INTERNATIONAL BUSINESS MACHINES CORPORATION  
**Insured's Address:** One New Orchard Road, Armonk, New York 10504

## General Liability

HDO G27852105

| State | Estimated Policy Premium ($) | Initial AARO Adjustment ($) | Total Estimated Written Premium ($) |
|-------|------------------------------|----------------------------|------------------------------------|
| Alabama | 1,691 | 0 | 1,691 |
| Arizona | 1,285 | 0 | 1,285 |
| Arkansas | 2,483 | 0 | 2,483 |
| California | 6,788 | 4,032 | 10,820 |
| Colorado | 1,957 | 0 | 1,957 |
| Connecticut | 630 | 0 | 630 |
| Delaware | 280 | 0 | 280 |
| Florida | 3,658 | 0 | 3,658 |
| Georgia | 2,356 | 0 | 2,356 |
| Hawaii | 2,351 | 0 | 2,351 |
| Idaho | 369 | 0 | 369 |
| Illinois | 2,798 | 0 | 2,798 |
| Indiana | 1,336 | 0 | 1,336 |
| Iowa | 704 | 0 | 704 |
| Kansas | 509 | 0 | 509 |
| Kentucky | 885 | 0 | 885 |
| Louisiana | 3,028 | 3 | 3,031 |
| Maine | 356 | 0 | 356 |
| Maryland | 2,250 | 0 | 2,250 |
| Massachusetts | 1,469 | 0 | 1,469 |
| Michigan | 1,464 | 0 | 1,464 |
| Minnesota | 1,557 | 0 | 1,557 |
| Mississippi | 852 | 0 | 852 |
| Missouri | 1,411 | 0 | 1,411 |
| Montana | 764 | 0 | 764 |
| Nebraska | 569 | 0 | 569 |
| Nevada | 657 | 0 | 657 |
| New Hampshire | 510 | 0 | 510 |
| New Jersey | 2,942 | 0 | 2,942 |
| New Mexico | 804 | 0 | 804 |
| New York | 9,741 | 614 | 10,355 |
| North Carolina | 2,743 | 0 | 2,743 |
| North Dakota | 77 | 0 | 77 |
| Ohio | 2,508 | 0 | 2,508 |
| Oklahoma | 964 | 0 | 964 |
| Oregon | 499 | 0 | 499 |
| Pennsylvania | 3,638 | 0 | 3,638 |
| Puerto Rico | 30 | 0 | 30 |
| Rhode Island | 135 | 0 | 135 |
| South Carolina | 815 | 0 | 815 |
| South Dakota | 170 | 0 | 170 |
| Tennessee | 1,274 | 0 | 1,274 |
| Texas | 12,364 | 642 | 13,006 |

**INTERNAT_05212016_**  
**05/16/2016**  
**Notice of Election Page 12 of 17**