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/12 p. 727 Account Ending 0-13001 Detail Continued Amount 07/13/12 AMERICAN EXPRESS TVLPHOENI X AZ DELTA AIR LINES INC. From: To: BOZEMAN SALT LAKE CITY ALBUQUERQUE SALT LAKE CITY BOZEMAN Carrier. Class: DL DL DL A DL A $900.20 Ticket Number: 00670760047064 Date of Departure:07/27 Passe

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

7/14/12 07/14/12 07/14/12 07/14/12 Amount AMERICAN EXPRESS TVLPHOENIX AZ DELTA AIR LINES INC. $900.20 From: To: Carrier: Class: BOZEMAN SALT LAKE CITY DL ALBUQUERQUE DL SALT LAKE CITY DL A BOZEMAN DL A Ticket Number: 00670760047064 Date of Departure:07/27 Passenger Name: HORNER/JOHN ROBE

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

ng 0-13001 Detail Continued Amount 07/13/12 AMERICAN EXPRESS TVLPHOENIX AZ DELTA AIR LINES INC. $900.20 From: To: Corner. Class: BOZEMAN SALT LAKE CITY DL ALBUQUERQUE DL SALT LAKE CITY DL A BOZEMAN DL A Ticket Number: 00670760047064 Date of Departure: 07/27 Passenger Name: HORNER/JOHN ROB

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