**BILLING REQUEST FORM**

**ACCOUNT NUMBER:** 23655  
**INSURED NUMBER:** 00000  
**MAIL TO INSURED:**  
**OVERWRITE:**  
**ADDR:**  
**ATTN:**  

**BILL TO:**
- **NAME:** International Business Machine Corp.
- **ATT.:** Mr. Carlile, Ins Dept.
- **ADDRESS:** Old Orchard Road
- **CITY:** Somers NY 10589 (Auditor's)

**FOR BILLING UNIT USE**

**BSD FUNCTIONS:**
- **CHECK IF INTERNATIONAL BUSINESS:** [ ] 

**BILLING DESCRIPTION:**  
**POLICY NUMBER:** CGL 3278678  
**INSURANCE DESCRIPTION:** Comprehensive General Liability

**ATTACHMENT DATE:** 5/21/86  
**EXPIRATION DATE:** 5/21/87  

**PRODUCT LINE:**  
**POLICY TYPE:**  
**POLICY VERIFICATION:**  
**LOCATION OF COVERAGE:** Various  
**COMMISSION:** [ ] Normal [ ] Agreed [ ] 29.1%  

**STATUS:**  
**REASON:**  
**TERM:**  
**UNDERWRITER:** [Signature]  
**PAYEE NAME & ADDRESS:** [Signature]

**ATTACHMENT DATE:**  
**EXPIRATION DATE:**  
**UNDERWRITER:** [Signature]  
**GROSS PREMIUM:** $76,455  
**PREMIUM DISCOUNT:** $80,483  
**NET PREMIUM:** $912,439  

**CURRENCY:**  
**PAYEE:**  
**RECEIVED IN:**  
**PAYABLE IN:**  
**LOCATION:**  
**INSTALLMENT DEPOSIT:**  
**# OF INSTALLMENTS:**  
**INSTALLMENT DUE DATE:**  
**PREMIUM:**  
**TAX:**  
**TAX DOLLARS:** $  
**TAX PAYEE:**  

**SPECIAL BILLING INSTRUCTIONS OR COMMENTS CAN BE NOTED ON BACK OF FORM.**

**MM 009859**