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AMEX Assurance Company Premium Baggage Protection Insurance Plan

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					                                                                                         AMEX Assurance Company
                                                                                         Premium Baggage Protection Insurance Plan
                                                                                         Post Office Box 981553
                                                                                         El Paso, TX 79998-9920
                                                                                         Toll Free Number 1-800-645-9700
                                                                                         Toll Free Fax     1-800-858-5971
Claim Form for Premium Baggage Protection Insurance Plan*
Claim # ____________
Instructions: Please complete the Claim Form and send it along with any applicable documentation to the address or fax number above.
                                                         Section 1: General Information
  Cardmember’s Name and Address:                                            American Express Card Account number used to purchase ticket:
  ___________________________________________                               ____________________________________________________
                                                                            Relationship of Claimant to Cardmember:
  ___________________________________________                               __Self __ Spouse __ Employee
  Cardmember's Contact Numbers:
                                                                            __Dependent Child (Under Age 23) __ Additional Cardmember
  Home: ____________________
  Work: ____________________                                                Claimant’s name if different from Cardmember:
                                                                            _____________________________________________
  FAX: ____________________
  e-mail: ____________________                                              Name of employer if tickets were charged to a Corporate Card:
                                                                            ___________________________________________________
                                                          Section 2: Travel Information
  Carrier: __ irline(s) __ Other (Explain)_______________                   Trip: __ Domestic Flight __ International Flight
 Name of Carrier(s): _________________           Ticket Purchase Date: ______________ Ticket Purchase Price: __________
                                                          Section 3: Claim Information
  Please describe your baggage incident:
   __________________________________________________________________________________________________________
  ___________________________________________________________________________________________________________
   City, State and Country of Incident: ___________________________              Date of incident: ______________________________
  __Checked Baggage (Loss occurred while in the Carrier’s custody)                Did you file a claim with the Carrier? __Yes __No
  __On board the carrier or in the terminal (Stolen while in your custody)        Were you reimbursed by Carrier?:__Yes__No
  __On the Hotel/Motel premises
  __ In the care of the Transportation Security Administration (TSA)
  __On transportation used to or from the terminal
  Please specify the type of transportation:___________________
                                             Section 4: Documents Required to Process Your Claim
  Please return this form as soon as possible with any of the following documentation you may have at this time. To expedite the processing
  of your claim, please send any additional information that you receive as soon as possible.*
   1. A copy of the carrier ticket or original record of charge (must confirm the passenger’s name, ticket number and verification of charge
        to your American Express account.)
      Additional document needed if the loss occurred while in the carrier’s custody:
   2. A copy of the claim form filed with the carrier, including the inventory (identifies all items and their cost claimed with the Carrier).
   3. A copy of the settlement letter from the carrier or verification of payment (documents settlement amount from Carrier).
     Additional document needed if loss occurred while on the carrier, in the terminal or on a common carrier to/from the terminal:
   2. A copy of a police or security report (documents verification of loss).
   3. An inventory of items including the approximate date (month/year) of purchase and the replacement cost of the item.
     Additional document needed if loss occurred while on hotel/motel premises:
   2. A copy of a police or hotel security report (documents verification of loss).
   3. An inventory of items including the approximate date (month/year) of purchase and the replacement cost of the item.
   4. A copy of the claim form filed with the hotel.
   5. A copy of the settlement letter from the hotel or verification of payment (documents settlement amount from hotel/motel).
      *Reminder: All your documentation must be returned within six months of the loss, even if the carrier has not settled your claim.
*Premium Baggage Protection Insurance Plan is underwritten by AMEX Assurance Company, Administrative Office, Phoenix, AZ. Coverage
is determined by the terms, conditions, and exclusions of Policy AX0923 or Policy PBP-IND and is subject to change with notice. This
document does not supplement or replace the Policy.
Some Additional Information about the Claim You are Filing:

1. This policy does not pay for Loss or Damage to Business Effects; cash or its equivalent, notes, accounts, bills,
   currency, deeds, food stamps or evidences of debt or intangible property; credit cards and other travel documents
   (including, but not limited to, passports and visas); securities; tickets and documents; artificial teeth and limbs,
   unless packed in Your Baggage; plants and animals; automobiles and automotive equipment; motorcycles; motors;
   aircraft, boats, or other conveyances; or property shipped as freight or shipped prior to the Covered Trip departure
   date.
2. Benefits will not be payable if the Loss for which coverage is sought was directly or indirectly, wholly or partially,
   contributed to or caused by the following: war or act of war, whether declared or undeclared; any act by customs or
   other governmental authority whether involving Your consent or by confiscation or requisition (except the
   Transportation Security Administration); defective workmanship, normal wear and tear and gradual deterioration;
   or any illegal act by or on behalf of the Covered Person.
3. You must be enrolled in the American Express Card Premium Baggage Protection Insurance Plan prior to the flight.
4. Tickets must be charged separately for each covered person and reflect a separate fee.

PLEASE READ THE INFORMATION BELOW AND SIGN THIS FORM PRIOR TO SUBMISSION.

I UNDERSTAND THAT ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY
INSURANCE COMPANY OR ANY PERSON, FILES A STATEMENT CONTAINING ANY MATERIALLY
FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION
CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH
IS A CRIME. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL
DAMAGES.

The claim information stated above is true and correct to the best of my knowledge and belief. I UNDERSTAND
THAT THE CLAIM FORM MUST BE COMPLETED AND THAT ALL REQUIRED DOCUMENTATION MUST
BE FILED AND SUBMITTED BEFORE ANY CLAIM UNDER THE PLAN CAN BE PROCESSED AND PAID.

I authorize American Express to release to TWG Innovative Solutions, Inc. and AMEX Assurance Company all
information regarding my account for the process of this claim. I further authorize TWG Innovative Solutions, Inc. and
AMEX Assurance Company to obtain copies of any reports and information needed to process my claim. In addition, I
hereby agree to cooperate with any designated representative of TWG Innovative Solutions, Inc. or AMEX Assurance
Company in the investigation of my claim and provide statements when requested to do so.


Cardmember’s Signature (Required)                                          Date



Claimant’s Signature (if not Cardmember)                                   Date
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