# "a" RATE SUBMISSION - NYSID FORM 129-C

## FOR NEW YORK STATE INSURANCE DEPARTMENT USE ONLY

| File No.:A | Received | Assigned | Unit |
| --- | --- | --- | --- |
| PACIFIC LOB codes: |  | Examiner | Disposition Code |
| Comments |  |  |  |

**Date Closed**

### A. INSURER INFORMATION
- **Insurer's NAIC Code:** 038-20281
- **Name of Insurer:** VIGILANT INSURANCE COMPANY
- **Insurer's File No.:** 13-1963496

### B. FILING INFORMATION
(1) **Type of Filing (Check one):** "a" Rate ☐ Umbrella ☐ Excess ☑
(2) **Is this risk in a market subject to Flex-rating?** Yes ☑ No ☐
(3) **Is this risk a renewal for your company?** Yes ☑ No ☐
(4) **If the answer to (2) and (3) are "Yes," does the rate or total premium for the current period differ from that of the expiring policy by more than +/−30%?** Yes ☐ No ☑

IF THE ANSWER TO (4) ABOVE IS "YES," THIS FILING IS SUBJECT TO THE SUPERINTENDENT'S PRIOR APPROVAL

### C. COVERAGE INFORMATION
- **Policy Form:** Claims-Made ☐ Occurrence ☑
- **Type of Coverage (use code):** 99
- **Name & Address of Insured:** INTERNATIONAL BUSINESS MACHINES CORP., ETAL (AS PER CONTROLLING U/L INSURANCE)
- **OLD ORCHARD ROAD**
- **ARMONK, NY 10504**
- **Policy Limits:**
  - Per Claim: $ 5,000,000.
  - Aggregate: $ 5,000,000.
  - SIR/Deductible: $ 0.
- **Policy Effective Date:** MAY 21, 1997
- **MFGR. INFO. HANDLING SYSTEM EQUIPMENT**
- **Insured's Principal Business or Activity**

### D. RATING INFORMATION
- **N/A**
- **Rating Class Code:** Rate
- **Exposure Base (use code):** 99
- **Total Premium:** $ 8,750.00

(1) **Was all or a portion of the Total Premium shown determined by application of a minimum premium?** Yes ☐ No ☑
(2) **If the answer to (1) is yes, and minimum premium only represents a portion of the Total Premium, indicate the nature and amount of the minimum premium:**
(3) **Describe the type and cost of any reinsurance affecting the rating of this risk:**
(4) **Identify, describe and explain each assignment element of judgement employed in determining the "a" rate applicable to this risk (attach additional sheets as necessary):**
70% OF THE UNDERLYING RATE PER MILLION DOLLARS OF COVERAGE CHARGED BY THE SCHEDULED UNDERLYING CARRIER WAS USED BASED UPON THE PRODUCTS EXPOSURE PRESENTED BY THIS RISK.

New York State Insurance Department
Form 129-C (Ed. 1/93)
Form 99-10-0224 (Rev. 2/93)