**CLAIM NOTIFICATION FORM**

| PRODUCING BRANCH: |  |
| --- | --- |
| AGENCY/BROKER NAME: | J&H Intermediaries |
| AGENCY NUMBER: | 18-200 |
| NAME OF INSURED: | International Business Machines Corp |
| INSURED'S MAILING ADDRESS: | Armonk, New York |
| MAJOR STATE: | NY |
| LENGTH OF TIME WITH COMPANY: |  |
| TYPE OF TRANSACTION: | NEW BUSINESS | RENEWAL | X | REWRITE |  |
| CORRECTION | ENDORSEMENT | CANCELLATION |  |
| REINSTATEMENT |  |
| EFFECTIVE DATE OF TRANSACTION: |  |
| RISK INFORMATION |
| SYM | POLICY # | MOD EFF DATE | EXPIR DATE | ANNL PREM | POLICY LIM/DED |
| ZIB# | 73966-87C | 5/1/87 | 5/1/88 | 25,000 | 25m/10 |
| ZBI# | ZXL 1328434 |  |  |  | 55m |
| BUSINESS/OPERATIONS INFORMATION |
| BUSINESS OF INSURED: |  |
| DESCRIPTION OF OPERATIONS: |  |
| PRODUCTS/EXPOSURES INSURED: |  |
| ADDITIONAL COMMENTS: | Change all claims to ZIB# |
| FORM PREPARED BY: | Quinn Johnson |
| DATE: | 7/16/87 |
| ROUTE TO: | MAJOR CASE UNIT - HO CLAIMS |
| Z 008752 |