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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

t Type: SUPPORTED REFUND $439.80 Carrier: Class: 66 YY 00 YY 00 YY 00 Date of Departure:07/21 07/24/12 TOYS Tit US NEW YORK NY HOBBY, TOY & GAME S28.30 07/25/12 AMERICAN EXPRESS TVLPHOENIX AZ JETBLUE AIRWAYS CORPORATI -$758.70 From: To: Carrier: Class: N/A N/A YY 00 WA YY 00

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 white coverage is in force under the Policy. For Dismemberment the Company will pay the applicable benefit amount as determined from the Table of Lo

escription TAXI:9A87 18:19 18:24 $6130 08/20/12 NYC TAXI MED 8P19 09EIRCOKLYN NY 718-6277097 51320 08/20/12 MYST( US NEW YORK NY HOBBY, TOY & GAME $3389 08/20/12 The Evolution Store New York NY CARD& SOUVENIR STORE $21884 08120/12 USER TECHNOLOGIES IN856-576-1039 CA 1RANSPORTATI $15.0

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

arture: 07/21 -$439.80 Carrier. Class: 86 YY 00 YY 00 YY 00 Date of Departure:07/21 07/16/12 07/24/12 TOYS 'R' US NEW YORK NY HOBBY, TOY & GAME -$28.30 07/25/12 AMERICAN EXPRESS TVLPHOENIX AZ JETBLUE AIRWAYS CORPORATI -$75830 From: To: N/A N/A N/A WA N/A Ticket Number: 279711708