# ACE GROUP SPECIALTY CLAIMS LOSS NOTIFICATION FORM

**Today's Date:** 18 May 2010

**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
- **Point of Contact:** _______________________
- **Phone Number:** _______________________

**Broker/Agent's Name & Contact Information**
- **Company Name:** AON RISK SERVICES NORTHEAST INC
- **Address:** 199 WATER STREET, 30TH FLOOR, NEW YORK, NY 10038
- **Point of Contact:** Nick Moore
- **Phone Number:** _______________________

**Policy Information**
- **Policy Number:** XOO G24907338
- **Policy Period:** 05/21/2010 - 05/21/2011
- **Limits of Liability:** 50,000,000 per agg 50,000,000
- **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:** _______________________
**Signature:** _______________________

**XS-28500 (10/09)**
**Page 1 of 1**

**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.**