# Mission Insurance Company Declarations

**No. M 832000**

## Mission Insurance Company
**LOS ANGELES, CALIFORNIA**

## SAYRE & TOSO, Inc.
**Underwriting Managers**

### In favor of:
**INTERNATIONAL BUSINESS MACHINES, CORPORATION**

### Address:
**ARMONK, NEW YORK**

### Type of Coverage: EXCESS UMBRELLA LIABILITY

### In the amount of:
**$5,000,000 PART OF $20,000,000 EXCESS OF 130,000,000**

### Term:
- **Beginning at 12:01 AM on the 21st day of MAY, 1976**
- **and ending at 12:01 AM on the 21st day of MAY, 1977**

### Standard time at the place of location of risks insured, and in accordance with terms and conditions of the form(s) attached and the Standard Clauses on the reverse side of this page.

### Forms:
- At time of Issuance this Policy contains a 2-page insuring Form and Endorsements 1 through 3 inclusive. Standard Clause 2 shall not apply.

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**Mission Insurance Company, Los Angeles, California (hereinafter called the Company), agrees with the assured named above, in consideration of the premium to be paid and subject to the limits of liability, exclusions, conditions and other terms of this policy, to provide insurance as set forth in the form(s) and endorsement(s) attached.**

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**Premium:**

| Due: | At Inception | 1st Anniversary | 2nd Anniversary |
|------|---------------|-----------------|-----------------|
| PREMIUM | $ 2,500.00 | $               | $               |
| Service Fee |            |                 |                 |
| Policy Fee |            |                 |                 |
| TOTAL | $ 2,500.00 | $               | $               |

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**IN WITNESS WHEREOF, this Company has executed and attended these presents; but this policy shall not be valid unless countersigned by SAYRE & TOSO, INC.**

**Secretary**  
**SAYRE & TOSO, INC.**  
**President**  
**NEW YORK, NEW YORK**  
**JUNE, 1976**  
**By**  
**John DeCicchis**

**ORIGINAL POLICY**

**FORM I-03-001 (1-70) BM**