**Hartford Accident and Indemnity Company**
**Hartford Casualty Insurance Company**

**The INSURER shall be The Company as designated herein by Co. Code:**

**Co. Code:** 5

**POLICY NO.:** 10 HU SG6756

**International Business Machine Corp. c/o Mr. Richard Faion, Ins. Dept. Armonk, N.Y. 10504**

**DECLARATIONS**

**Previous Policy No.:** 10 XS SG4445

**Items:**

1. **Named Insured and Mailing Address:**
   - The Named Insured is: Individual ☐ Corporation ☐ Partnership ☐ Other: ___________

2. **Policy Period:**
   - Inception (Mo. Day Yr): 5/21/67
   - Expiration (Mo. Day Yr): 5/21/88
   - 12:01 A.M. standard time at the address of the named insured as stated herein.

3. **Premium:**
   - Advance Premium: $ 833,000
   - Minimum Premium: $ See Attachment Endorsement
   - Rate Per: Premium Base

4. **Self-insured Retention:** $ 10,000

5. **Limits of Liability:**
   - Each occurrence: $ 10,000,000
   - Aggregate: $ 10,000,000

**6. Schedule of Underlying Insurance Policies**

**SEE ATTACHED EXTENSION SCHEDULE OF UNDERLYING INSURANCE POLICIES FORMING A PART OF POLICY. XL 11-3 (Ed. 5/85)**

The above numbered Umbrella policy is completed by:
(a) this Declarations, Form XL-10;
(b) the Policy Provisions, Form XL-12;
(c) the Policy Jacket, Form 6153;
(d) any Endorsements forming part of the policy at issue. (E) Notice to Policyholder XL 269-G
Form Numbers of Endorsements Forming Part of Policy At Issue:

See Attach G 2240-2E

**Date:** 8/17/87
**Agency at:** NY, NY
**Countersigned by:** William M. O'Donnell
**Authorized Agent**

**Form XL-10-1 Printed in U.S.A.**