# CHECK SHEET

- New: Direct Excess
- Renewal:
- Reinsured: International Business Machines Corp.
  - Address: 590 Madison Ave., New York, N.Y.
  - Broker: Johnson & Higgins
  - Address: 63 Wall St., New York, N.Y. 10005
- Assign Contract No.: NSX-5085
- Signed Copies: 1
- Copies: 7
- Issue Cover Note: -
- Premium: $4,000
- Commission: 10%
- Breakdown by Line: Umbrella
- Breakdown by State: N.Y.
- Make Up Index Cards
- Special Retrocession: Prudential Ins. Co. of Great Britain, $1,000, 825/Net being 1000 less 17% Comm.
- Filing
- Countersignature
- Inspection Requirements
- Notification to Claim Dept.
- Is Claim Review Required?
- Have Claim Handling Facilities been checked?

per mo