# Billing Request Form

## Invoice Details
- **Account Number:** 2305
- **Insured Number:** 00000
- **Account Administrator:** R. Michel

## Billing Information
- **Bill To:**
  - **Name:** International Business Machines Corp.
  - **Att.:** Attn: Mr. J. Myracle, Law Dept.
  - **Address:** Old Orchard Road, Armonk, New York 10504
  - **City:** Armonk
  - **State:** New York
  - **Zip Code:** 10504

## Policy Details
- **Policy Number:** CGL 3278678
- **Insurance Description:** Comprehensive General Liability
- **Attachment Date:** 5/21/85
- **Expiration Date:** 5/21/86
- **Location:** Various
- **Commission:** 48.5%
- **Underwriter:** Zurich Ins Co
- **Payee Name & Address:** PricewaterhouseCoopers, New York
- **Currency Payable In:** USD
- **Premium Discount:** $329.45
- **Net Premium:** $3,294.50
- **Installment Deposit:** $3,294.50
- **TAX:** $0
- **Tax Dollars:** $0
- **Tax Payee:** PricewaterhouseCoopers
- **Special Billing Instructions or Comments:** Can be noted on back of form.

## Additional Information
- **Product Line:** 90
- **Policy Type:** 400
- **Policy Verification:** 1
- **Status:** 1
- **Reason:** 
- **Term:** 12
- **Attachment Date:** 5/21/85
- **Expiration Date:** 5/21/86
- **Underwriter:** Zurich Ins Co
- **Payee:** 1519E
- **Location:** 099
- **Premium:** $3,294.50
- **Commission:** 48.5%

## Miscellaneous
- **MM:** 009854