**CLAIM NOTIFICATION FORM**

**PROCESSING BRANCH:**  
**AGENCY/BROKER NAME:** Johnson & Higgins Formul  
**AGENCY NUMBER:** 18-200  
**NAME OF INSURED:** Armonk, NY Intercontinental Business Meal  
**INSURED'S MAILING ADDRESS:** Armonk, NY  

**MAJOR STATE:**  
**LENGTH OF TIME WITH COMPANY:**  

**TYPE OF TRANSACTION:** NEW BUSINESS ☐ RENEWAL ☑ REWRITE ☐  
**CORRECTION ☐ ENDORSEMENT ☐ CANCELLATION ☐**  
**REINSTATEMENT ☐**  

**EFFECTIVE DATE OF TRANSACTION:** 5/21/87  

**RISK INFORMATION**  
**STM POLICY #:** 21B 93,916-87-C  
**MOD EFF DATE:** 5/21/87  
**EXPIR DATE:** 5/21/88  
**ANNUAL PREMIUM:** $25,000  
**POLICY LIMIT/DED:** 2.5M PTO  
**24#:** SXL 132843H  
**5.5M XLS**  

**BUSINESS/OPERATIONS INFORMATION**  
**BUSINESS OF INSURED:**  
**DESCRIPTION OF OPERATIONS:**  
**PRODUCTS/EXPOSURES INSURED:**  
**ADDITIONAL COMMENTS:**  

**FORM PREPARED BY:** J. Crutten  
**DATE:** 7-20-87  

**ROUTE TO:** MAJOR CASE UNIT - HO CLAIMS  
**Z 008750**