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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

ount 07/10/12 AMERICAN EXPRESS TVLPHOENIX AZ $1,180.20 UNITED AIRLINES From: To: Carrier. Class: ST THOMAS CYRIL E SAN JUAN LUIS MUNO UA PHILADELPHIA INTER UA N/A re 00 N/A re 00 Ticket Number: 01670749012262 Date of Departure:07/14 Passenger Name: INDYKE/DARREN K Document Type: PASSENGER TICK

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

UDERDALE FL 9544913170 Description Prke AVIATION PRODUCTS $241.67 $241.67 04/29/12 UNITED AIRLINES HOUSTON TX UNITED AIRLINES NOM: Trx PHILADELPHIA INTER PALM BEACH INTERNA WA WA N/A Tkket Number Passenger Name: VISOSKI/LARRYNAR Document Type: SPECIAL SERVICE TICKET Carrier: Class: UA 00 YY

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

Amount 07/10/12 AMERICAN EXPRESS PAPHOENIX AZ 31,180.20 UNITED AIRLINES From: To: Carrier Class: ST THOMAS CYRIL E SAN JUAN LUIS MUNO UA PHILADELPHIA INTER UA N/A YY 00 N/A YY 00 Ticket Number: 01670749012262 Date of Departure: 07114 Passenger Name: INDYKE/DARREN K Document Type: PASSENGER TIC