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

**Broker/Agent's Name & Contact Information**
- **Company Name:** AON RISK SERVICES NORTHEAST INC
- **Address:** 199 WATER STREET NEW YORK, New York 10038
- **Phone Number:** [Not provided]

**Policy Information**
- **Policy Number:** XOO G27983212 003
- **Policy Period:** 05/21/2018 - 05/21/2019
- **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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