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tion Date Rental: MIAMI FL 06/10/06 Return: W. PALM BCH FL 08/1W06 Agreement Num Renter Name:

If Your proof of loss demonstrates that Your claim is payable according to this Plan, We will reimburse You the amount charged to Your Account for the Event Ticket You purchased, loss any reimbursement You may receive, up to the maximum coverage limit as stated in the Coverage Overview section. Any payment that We

ness lunches, pre-theater, or private events. 57 W. 48th St 212-262-6200. www.ajmaxwells.com. If the

It Your proof of loss demonstrates that Your claim is payable according to this Plan, We will reimburse You the amount charged to Your Account for the Event Ticket You purchased, less any reimbursement You may receive, up to the maximum coverage limit as stated in the Coverage Overview section. Any payment that We

Customer Service. • Please print clearly In blue or black Ink only In the boxes provided. You mayvisit the American Express PdvacyStatement at VW/W. americanexpresszonSivacy for more details andtoset your email preferences. Large Print and Braille Statements 1-800-525-3355 Travel Emergency and

If Your proof of loss demonstrates that Your claim is payable according to this Plan, We will reimburse You the amount charged to Your Account for the Event Ticket You purchased, less any reimbursement You may receive, up to the maximum coverage limit as stated in the Coverage Overview section. Any payment that We

ness lunches, pre-theater, or private events. 57 W. 48th St. 212-262-6200. www.ajmaxwells.com. If th

. If Your proof of Ion demonstrates that Your claim is payable according to this Plan, We will reimburse You the amount charged to Your Account for the Event Ticket You purchased, less any reimbursement You may receive, up to the maximum coverage limit as stated in the Coverage-OvervIew section. Any payment that We