# DECLARATIONS - SPECIAL COVERAGE POLICY

## FIRST STATE INSURANCE COMPANY

**Named Insured and Mailing Address:**

- **International Business Machines, Inc., et al (see Endorsement #1)**
- **101 Old Orchard Road**
- **Armonk, New York 10504**

## Item 1: Policy Period
- From: May 21, 1980
- To: May 21, 1981
- 12:01 A.M., Standard Time at the address of the named insured as stated herein.

## Item 2: Premium
- **(A)** Advance Premium: $4600.
- **(B)** Rate: $2500.
- Minimum Premium: $4600.
- If the Policy Period is more than one year and the premium is to be paid in installments, the premium is payable on:
  - Effective Date: $---
  - 1st Anniversary: $---
  - 2nd Anniversary: $---

## Item 3: Coverage
- Excess Umbrella Liability

## Item 4: Limits of Liability
- The limit of the Company's liability shall be as stated herein, subject to all the terms of this policy having reference thereto.
- See Endorsement #2

## Item 5: During the past three years no insurer has cancelled insurance issued to the named insured, similar to that afforded hereunder, unless otherwise stated herein.

**Countersigned by:** [Signature]

**Date of Issue:** 4-14-80