**BILLING REQUEST FORM**

- **ACCOUNT #:** 23055
- **INSURED:** 00000
- **MAIL TO INSURED:** 
- **OVERRIDE ADDRESS:** 
- **ATTENTION:** 0363
- **ACCOUNT ADMINISTRATOR:** R. Michel

**BILL TO:**
- **NAME:** Intl. Business Machines Corp.
- **ATTN:** Mr. J. M. Castello, Ins. Dept.
- **ADDRESS:** 2000 Purchase Street
- **CITY, STATE:** Purchase NY

**INSURED NAME & ADDRESS:**
- **SAME:** CGL 3278678-02
- **RENEWAL OF NUMBER:** 44141054

**PLEASE CHECK BOXES BELOW WHEN APPLICABLE:**
- **POLICY IS CLAIMS MADE:** 
- **CHECK HERE, IF INTERNATIONAL BUSINESS:** 

**POLICY IS AUDITABLE:** 

**POLICY NUMBER:** CGL 3278678-03
- **INSURANCE DESCRIPTION:** Comprehensive General Liability
- **ATTACHMENT EXPIRATION DATES:** 5/21/87 to 5/21/88
- **LOCATION OF COVERAGE:** Various

**UNDERWRITER:** Zurich Ins. Co.
- **PAYEE NAME AND ADDRESS:** Direct-Ny

**GROSS PREMIUM:** $1,212,572
- **PREMIUM DISCOUNT & NET PREMIUM (WORKERS COMPENSATION ONLY):**
- **COMMISSION:** 40.2%
- **SHARE COMMISSION:** 
- **TO BE SHARED WITH:** 

**FOREIGN CURRENCY TRANSACTIONS:**
- **PREMIUM TO BE RECEIVED IN:** US$
- **PREMIUM TO BE PAID TO INSURER IN:** US$

**INSTALLMENTS (INDICATE TOTAL # OF PAYMENTS, WHETHER MONTHLY, ANNUAL, ETC. & AMOUNT DUE ON 1ST PAYMENT):**
- **# OF INSTALLMENTS:** 11
- **TO BE PAID:** monthly
- **WITH A DEPOSIT OF:** $10,055
- **@101,047**

**TAX PAYMENTS (FOR FOREIGN TAX ENTRIES PLEASE CONSULT BILLING UNIT):**
- **DOMESTIC:** 
- **% TAX DOLLARS:** 
- **TAX PAYEE:** 

**BSD NO. FOR BILLING UNIT USE ONLY!!**
- **BSD:** 
- **BILL TYPE:** 
- **INCOME CALC SHARE COMM:** 
- **CURR.:** 
- **ORIG. INV.:** 
- **SUSPENSE:** 
- **ISSUE:** 
- **NO. OF INSTS:** 
- **INST. PERIODS:** 
- **INST TERM:** 
- **INST DEPOS:** 

**POLICY NO.:**
- **DESCRIPTION:** 
- **PROD LINE:** 
- **POLICY TYPE:** 
- **POL VER:** 
- **STS:** 
- **TERM:** 
- **ATTACH:** 

**EXPIRATION:** 
- **UNDERWRITER:** 
- **PAYEE:** 
- **LOC.:** 
- **AMOUNT:** 
- **B/C:** 
- **COMM RATE:** 
- **TAX:** 

**MM 009868**