# Chubb Specialty Claims Loss Notification Form

## Forward by Fax, Mail or E-mail To:
- **Chubb Excess**
  - P.O. Box 5103
  - Scranton, PA 18505-0510
  - Fax No.: (866)635-5687
  - Email: ChubbClaimsFirstNotice@Chubb.com

## 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, New York 10504
- **Phone Number:** [Not provided]

## Broker/Agent's Name & Contact Information
- **Company Name:** AON RISK SERVICES NORTHEAST INC
- **Address:** ONE LIBERTY PLAZA NEW YORK, New York 10006
- **Phone Number:** [Not provided]

## Policy Information
- **Policy Number:** XOO G27983212 004
- **Policy Period:** 05/21/2019 - 05/21/2020
- **Limits of Liability:** $50,000,000 per $50,000,000 agg
- **Self-Insured Retention/Deductible:** $N/A

## Loss Information
- **Date of Incident/Claim:** [Not provided]
- **Location:** [Not provided]
- **Claimant Name/Address:** [Not provided]
- **Description of Loss:** [Not provided]

## Please list all attached or enclosed documentation:
- [ ] (check if none provided)

## Name of Person Completing This Form: [Not provided]
## Signature: [Not provided]

**XS-28500a (08/13)**
©Chubb. 2016. All rights reserved.
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