# ACE USA Specialty Claims Loss Notification Form

**Today's Date:** 3 June 2008

**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 North Castle Drive, Mail Drop 222, Armonk, NY 10504
- **Point of Contact:** ________
- **Phone Number:** ________

**Broker/Agent's Name & Contact Information**
- **Company Name:** ARTHUR J GALLAGHER RISK MANAGEMENT SERVICES INC
- **Address:** HOLLY POND PLAZA, 1281 MAIN ST, STAMFORD CT 06902-3548
- **Point of Contact:** Kathryn S. Carroll
- **Phone Number:** ________

**Policy Information**
- **Policy Number:** XCP G2464845A
- **Policy Period:** 05/21/2008 - 05/21/2009
- **Limits of Liability:** 25,000,000 per 25,000,000 agg
- **Self-Insured Retention/Deductible:** 0.00

**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:** ________

**FORWARD BY FAX, MAIL OR E-MAIL TO:**
- ACE USA Specialty Claims
- 140 Broadway, 40th Floor
- New York, NY 10005
- Fax No.: (646) 458-5933
- CasualtyRiskExcessFirstNotice@ace-ina.com

**NOTICE: THESE POLICY FORMS AND THE APPLICABLE RATES ARE EXEMPT FROM THE RATING REQUIREMENTS OF THE NEW YORK STATE INSURANCE DEPARTMENT. HOWEVER, SUCH FORMS AND RATES MUST MEET THE MINIMUM STANDARDS OF THE NEW YORK INSURANCE LAWS AND REGULATIONS.**