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ll pay the applicable benefit amount as determined from the Table of Losses for the benefits listed below if a Covered Person suffers a loss from an Injury while coverage is in force under the Policy. For Dismemberment the Company win pay the applicable benefit amount as determined from the Table of Los

0102 Passenger Name: Document Type: SUPPORTED REFUND 08/05/12 AMERICAN EXPRESS TVLPHOENIX AZ AMERICAN MRUNES INC From: To: Carrier: Class: SAN FRANCISCO INTL N.Y. J F KENNEDY I AA WA YY 00 WA YY 00 WA YY 00 Ticket Number 00171230129722 Date of Departure: 08/07 Passenger Name: Document Type:

ll pay the applicable benefit amount as determined from the Table of Losses for the benefits listed below if a Covered Person suffers a loss from an Injury while coverage is in force under the Policy. For Dismemberment the Company will pay the applicable benefit amount as determined from the Table of Lo

sengerName: Document Type: SUPPORTED REFUND 08/05/12 AMERICAN EXPRESS 1VLPHOENIX AZ -$679.80 AMERICAN MRUNES INC From: To: Carrier: Class: SAN FRANCISCO INTL N.Y. J F KENNEDY I AA WA YY 00 WA YY 00 WA YY 00 Ticket Number: 00171230129722 Date of Departure:08/07 Passenger Name: Document Type:

ll pay the applicable benefit amount as determined from the Table of Losses for the benefits listed below if a Covered Person suffers a loss from an Injury while coverage is in force under the Policy. For Dismemberment the Company will pay the applicable benefit amount as determined from the Table of Lo

/18/12 NY 52.900.00 Description 06/19/12 ORBITZ MANKATO MN UNITED AIRLINES From: To: Carrier Class: ALBUQUERQUE LOS ANGELES INTERN UA SAN FRANCISCO INTL AS N/A YY 00 N/A YY 00 Ticket Number: Date of Departure: 06/21 Passenger Name: Document Type: PASSENGER TICKET 06/19/12 ORBITZ MANKATO