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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

Y WINE $16.33 $1,350.92 07/24/12 AMERICAN EXPRESS TVLPHOENIX AZ US AIRWAYS INC. From: To: MINNEAPOLIS INTERN DENVER INTL APT ALBUQUERQUE DENVER INTL APT MINNEAPOLIS INTERN Ticket Number: 03771202101122 Passenger Name: Document Type: PASSENGER TICKET Carrier. US US US US Date of Departure: 08

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

6-747-0495 NY $1,350.92 WINE 07/24/12 AMERICAN EXPRESS TVLPHOENIX AZ $71420 US AIRWAYS INC. From: To: Carrier. Class: MINNEAPOUS INTERN DENVER INTL APT US ALBUQUERQUE US DENVER INTL APT US MINNEAPOUS INTERN US Ticket Number: 03771202101122 Date of Departure:08/02 Passenger Name: Document T

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

89.14 07/31/12 UNITED AIRLINES HOUSTON TX 3525.90 UNITED AIRLINES From: To: Caroler. Class: PALM BEACH INTERNA HOUSTON INTERCONTI UA 00 DENVER INTL APT UA 00 ALBUQUERQUE UA 00 N/A YY 00 Ticket Number: Date of Departure: 08/04 Passenger Name: RODGERS/DAVIDNMR Document Type SPECIAL SERVICE

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

747-0495 NY WINE $1,350.92 07/24/12 AMERICAN EXPRESS TVLPHOENIX AZ $714.20 US AIRWAYS INC. From: To: Carrier: Class. MINNEAPOLIS INTERN DENVER INTL APT US ALBUQUERQUE US DENVER INTL APT US MINNEAPOLIS INTERN US Ticket Number Date of Departure:08)02 Passenger Name: Document Type: PASSENGER