# 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: ACEClaimsFirstNotice@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
- **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, New York 10038
- **Point of Contact:** [ ]
- **Phone Number:** [ ]

## Policy Information
- **Policy Number:** XOO G27983212 002
- **Policy Period:** 05/21/2017 - 05/21/2018
- **Limits of Liability:** $50,000,000 per $50,000,000 agg
- **Self-Insured Retention/Deductible:** $N/A

## 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)
©Chubb. 2016. All rights reserved.
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