# ACE GROUP 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, NY 10504
- **Point of Contact:** _______________________
- **Phone Number:** _______________________

**Broker/Agent's Name & Contact Information**
- **Company Name:** Aon Risk Services
- **Address:** 199 Water Street, New York, NY 10038
- **Point of Contact:** Nick Moore
- **Phone Number:** _______________________

**Policy Information**
- **Policy Number:** XOO G27380037
- **Limits of Liability:** $50,000,000 per $50,000,000 agg
- **Self-Insured Retention/Deductible:** $0
- **Policy Period:** 05/21/2014 to 05/21/2015

**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-28500a (08/13)**
**© 2013**
**Page 1 of 1**

**FORWARD BY FAX, MAIL OR E-MAIL TO:**
- ACE Excess
- P.O. Box 5103
- Scranton, PA 18505-0510
- Fax No.: (866)635-5687
- ACEClaimsFirstNotice@acegroup.com