**IBM INSURANCE COMPANY**

**110 William Street, New York, New York 10038**

**CERTIFICATE OF INSURANCE**

**FOR THE PERIOD FROM [DATE] TO [DATE]**

**TO:**

**[INSURED'S NAME]**

**[INSURED'S ADDRESS]**

**This Certificate evidences the fact that the undersigned Company has entered into an insurance contract with the Insured as set forth below.**

**I. DESCRIPTION OF INSUREDB**

The Insured is engaged in the business of [describe the nature of the business].

**II. POLICY NUMBER**

[Policy Number]

**III. LIMITS OF INSURANCE**

The limits of insurance applicable to the property described herein are as follows:

- **Property Damage Liability:** $[Amount]
- **Personal Injury Liability:** $[Amount]

**IV. AS USED HEREIN**

As used herein, "hazardous properties" include radioactive, toxic or explosive properties; "nuclear material" means source material, special nuclear material or byproduct materials; "source material," "special nuclear material," and "byproduct material" have the meanings given them in the Atomic Energy Act of 1954 or in any law amendatory thereof; "spent fuel" means any fuel element or fuel component, solid or liquid, which has been used or exposed to radiation in a nuclear reactor; "waste" means any nuclear material (1) containing byproduct material and (2) resulting from the operation by any person or organization of any nuclear facility included within the definition of nuclear facility under paragraph (a) or (b) thereof; "nuclear facility" means:

(a) any nuclear reactor, the substance of which may be used for the production of nuclear energy;

(b) equipment or device designed or used for (1) separating the isotopes of uranium or plutonium, (2) processing or utilizing spent fuel, or (3) handling, processing or packaging waste;

(c) any equipment or device used for the processing, fabricating or alloying of special nuclear material if at any time the gross total amount of such material in the custody of the Insured at the premises where such equipment or device is located consists of or contains more than 25 grams of plutonium or uranium 233 or a combination thereof, or more than 250 grams of uranium 235 or a combination thereof, or more than 100 grams of any other fissile material.

(d) any structure, building, excavation, premises or place prepared or used for the storage or disposal of waste, and includes the site on which any of the foregoing is located; all operations conducted on such site and all premises used for such operations; "nuclear reactor" means any apparatus designed to use to sustain nuclear fission in a self-sustaining chain reaction or to contain a critical mass of fissionable material.

**V. WITH RESPECT TO INJURY TO OR DESTRUCTION OF PROPERTY, THE WORD "INJURY" OR "DESTRUCTION" INCLUDES ALL FORMS OF RADIOACTIVE CONTAMINATION OF PROPERTY.**

**VI. THIS CERTIFICATE MAY BE CANCELLED BY EITHER PARTY UPON WRITTEN NOTICE, SUCH NOTICE TO BE NOT LESS THAN THE NUMBER OF DAYS SET FORTH IN ITEM 6 OF THE DECLARATIONS. IF CANCELLATION IS AT THE REQUEST OF THE INSURED, ADJUSTMENT OF PREMIUM SHALL BE AT SHORT RATE AND IF CANCELLED BY THE COMPANY, ADJUSTMENT SHALL BE PRO RATA. HOWEVER, IN THE EVENT OF CANCELLATION OR NON-RENEWAL OF THE UNDERLYING INSURANCE IMMEDIATELY FOLLOWING THIS CERTIFICATE, THIS CERTIFICATE TERMINATES ON THE SAME DATE WITHOUT NOTICE TO THE INSURED. THE COMPANY MAY, HOWEVER, CANCEL THIS CERTIFICATE ABSOLUTELY ON FIVE (5) DAYS' NOTICE FOR NON-PAYMENT OF PREMIUM DUE. NOTICE SHALL BE GIVEN BY THE INSURED TO THE COMPANY AT 110 William Street, New York, New York 10038 and by the Company to the Insured at the latter's address as shown in the Declarations. Notice by the Company to the first named Insured, if more than one, shall be deemed notice to any other interests included as an Insured.**

**IN WITNESS WHEREOF The Company has caused this Certificate to be signed by its Vice President and Secretary, but same shall not be binding upon Company unless counter-signed by an authorized representative of the Company.**

**Albert C. Moore**  
**Secretary**  
**[Date]**  

**[President's Signature]**  
**[Title]**  
**[Date]**