Premier Rewards Gold Card p.

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PATSY DEMARCO FUCITO

Closing Date 04/27/18 Account Ending 9-97002

Membership Rewards® Points

New Balance $5,602.56 Available and Pending as of 03/31/18
29,287
Payment Due Date 05/22/18 For more details about Rewards, please
visit americanexpress.com/rewardsinfo
Late Payment Warning: If we do not receive your payment by the Payment Account Summary
Due Date of 05/22/18, you may have to pay a late fee of up to $38.00.
Previous Balance $8,789.19
Payments/Credits -$8,789.19
New Charges +$5,564.56
Fees +$38.00

New Balance $5,602.56

See page 2 for important information about your account.
Days in Billing Period: 30

As a reminder, as of 03/29/2018, our records indicate that your account is Customer Care
enrolled in one or more optional product(s) which may generate a charge
to your account. Please see Page 7 for more details. Pay by Computer
americanexpress.com/pbc

Important Information: To access the most up to date version of your Customer Care Pay by Phone
Cardmember Agreement, please log in to your Account at 1-800-327-2177 1-800-472-9297
www.americanexpress.com.
See Page 2 for additional information.
Learn how to take advantage of your Pay Over Time feature on page 7

Your account is currently enrolled in one or more optional travel insurance

product(s). For refund requests, please see Page 9 for your Travel
Insurance Premium Refund/Credit form.

Please fold on the perforation below, detach and return with your payment

Payment Coupon Pay by Computer Pay by Phone Account Ending 9-97002

Do not staple or use paper clips americanexpress.com/pbc 1-800-472-9297
Enter 15 digit account # on all payments.
Make check payable to American Express.

PATSY DEMARCO FUCITO Payment Due Date

8 JONES LN 05/22/18
SAGAMORE BCH MA 02562-2538
Amount Due
$5,602.56

Check here if your address or AMERICAN EXPRESS

phone number has changed. P.O. BOX 1270
Note changes on reverse side. NEWARK NJ 07101-1270
 PATSY DEMARCO FUCITO Account Ending 9-97002 p. 2/10

Payments: Your payment must be sent to the payment address shown on your statement and must be received by 5 p.m. local time at that address
to be credited as of the day it is received. Payments we receive after 5 p.m. will not be credited to your Account until the next day. Payments must
also: (1) include the remittance coupon from your statement; (2) be made with a single check drawn on a US bank and payable in US dollars, or with a
negotiable instrument payable in US dollars and clearable through the US banking system; and (3) include your Account number. If your payment
does not meet all of the above requirements, crediting may be delayed and you may incur late payment fees and additional interest charges.
Electronic payments must be made through an electronic payment method payable in US dollars and clearable through the US banking system. If
we accept payment in a foreign currency, we will convert it into US dollars at a conversion rate that is acceptable to us, unless a particular rate is
required by law. Please do not send post-dated checks as they will be deposited upon receipt. Any restrictive language on a payment we accept will
have no effect on us without our express prior written approval. We will re-present to your financial institution any payment that is returned unpaid.
Permission for Electronic Withdrawal: (1) When you send a check for payment, you give us permission to electronically withdraw your payment
from your deposit or other asset account. We will process checks electronically by transmitting the amount of the check, routing number, account
number and check serial number to your financial institution, unless the check is not processable electronically or a less costly process is available.
When we process your check electronically, your payment may be withdrawn from your deposit or other asset account as soon as the same day we
receive your check, and you will not receive that cancelled check with your financial account statement. If we cannot collect the funds electronically
we may issue a draft against your deposit or other asset account for the amount of the check. (2) By using Pay By Computer, Pay By Phone or any
other electronic payment service of ours, you give us permission to electronically withdraw funds from the deposit or other asset account you specify
in the amount you request. Payments using such services of ours received after 8:00 p.m. MST may not be credited until the next day.
How We Calculate Your Balance: We use the Average Daily Balance (ADB) method (including new transactions) to calculate the balance on which
we charge interest for Pay Over Time balances on your Account. Call the Customer Care number listed below for more information about this
balance computation method and how resulting interest charges are determined. The method we use to figure the ADB and interest results in daily
compounding of interest.
Paying Interest: If you have a Pay Over Time balance, your due date is at least 25 days after the close of each billing period. We will begin charging
interest on transactions added to a Pay Over Time balance as of the date they are added. However, we will not charge interest on charges added to a
Pay Over Time balance automatically (for example, Sign & Travel and Extended Payment Option) if you pay the Account Total New Balance by the due
date each month.
Foreign Currency Charges: If you make a Charge in a foreign currency, we will convert it into US dollars on the date we or our agents process it. We
will choose a conversion rate that is acceptable to us for that date, unless a particular rate is required by law. The conversion rate we use is no more
than the highest official rate published by a government agency or the highest interbank rate we identify from customary banking sources on the
conversion date or the prior business day. This rate may differ from rates in effect on the date of your charge. Charges converted by establishments
will be billed at the rates such establishments use.
Credit Balance: A credit balance (designated CR) shown on this statement represents money owed to you. If within the six-month period following
the date of the first statement indicating the credit balance you do not request a refund or charge enough to use up the credit balance, we will send
you a check for the credit balance within 30 days if the amount is $1.00 or more.

Credit Reporting: We may report information about your Account to credit bureaus. Late payments, missed payments, or other defaults on your
Account may be reflected in your credit report.

Customer Care & Billing Inquiries 1-800-327-2177 Hearing Impaired

International Collect 1-336-393-1111 TTY: 1-800-221-9950 Website: americanexpress.com
Large Print & Braille Statements 1-800-327-2177 FAX: 1-800-695-9090
Lost or Stolen Card 1-800-992-3404 In NY: 1-800-522-1897 Customer Care
Express Cash 1-800-CASH-NOW & Billing Inquiries Payments
P.O. BOX 981535 P.O. BOX 1270
EL PASO, TX NEWARK NJ 07101-
79998-1535 1270

Change of Address
If correct on front, do not use.
Pay Your Bill with AutoPay
To change your address online, visit www.americanexpress.com/updatecontactinfo
For Name, Company Name, and Foreign Address or Phone changes, please call Customer Care. Avoid late fees
Please print clearly in blue or black ink only in the boxes provided. Save time
Deduct your payment from your bank
Street Address account automatically each month

Visit americanexpress.com/autopay
City, State today to enroll.
Zip Code

Area Code and

Home Phone
Area Code and
Work Phone For information on how we protect your
privacy and to set your communication
Email and privacy choices, please visit
www.americanexpress.com/privacy.
 Premier Rewards Gold Card p. 3/10

PATSY DEMARCO FUCITO

Closing Date 04/27/18 Account Ending 9-97002

Payments and Credits

Summary

Total
Payments -$8,789.19
Credits $0.00
Total Payments and Credits -$8,789.19

Detail *Indicates posting date

Payments Amount
04/23/18* PATSY DEMARCO FUCITO ONLINE PAYMENT - THANK YOU -$8,789.19

New Charges
Summary
Total
PATSY DEMARCO FUCITO 9-97002 $1,486.71
DOMINICK FUCITO 9-93019 $3,154.72
TESS R FUCITO 9-92037 $105.32
ALEXXA F FUCITO 9-92045 $73.06
PETER L MARINOS 9-91054 $744.75
Total New Charges $5,564.56

Detail *Indicates posting date

PATSY DEMARCO FUCITO

Card Ending 9-97002
Amount
03/27/18 OPTUMRX 000000001 IRVINE CA $7.10
03/29/18 AMAZON.COM AMZN.COM/BILL WA $21.77
MERCHANDISE
03/31/18 WWW.ITUNES.COM/BILL CUPERTINO CA $12.74
DIRECT MKTG INTERNET
04/01/18 SVC-PROTECTION ADV (800)626-2224 GA $11.34
SERVICE PLAN
04/02/18 BOURNE DENTAL ASSOC. LLC 000000001 BOURNE MA $173.00
5087592724
04/02/18 AMAZON MKTPLACE PMTS AMZN.COM/BILL WA $18.90
BOOK STORES
04/03/18 BOURNE DENTAL ASSOC. LLC 000000001 BOURNE MA $562.00
5087592724
04/03/18 ENTERPRISE RENT-A-CAR BUZZARDS BAY MA $135.72
Location Date
Rental: BUZZARDS BAY MA 18/03/28
Return: BUZZARDS BAY MA 18/03/30
Agreement Number: 1SVWZD
Renter Name: DAMARCO-FUCITOPATSY
04/05/18* TRANSACTION PROCESSED BY AMERICAN EXPRESS $19.95
PREM CAR RENTAL PROTECTION 800-326-2078
CRA081027580 03/28/2018 BUZZARDS BAY
04/07/18 AMAZON MKTPLACE PMTS AMZN.COM/BILL WA $13.99
BOOK STORES

Continued on reverse
 PATSY DEMARCO FUCITO Account Ending 9-97002 p. 4/10

Detail Continued *Indicates posting date

Amount
04/10/18 PINEHILLS GULF 000000000964010 PLYMOUTH MA $57.11
5087739160
04/10/18 SCORESENSE.COM 800-679-6327 TX $5.95
CREDITMONITO
04/11/18 MYLIFE.COM INC 698977894924992 LOS ANGELES CA $1.00
MISC PERSONAL SERVICE
04/11/18 MYLIFE.COM INC 698977894924992 LOS ANGELES CA $17.95
MISC PERSONAL SERVICE
04/12/18 BANFIELD-PET*WPPAYMVANCOUVER WA $41.95
04/13/18 MIRBEAU INN PINEHILLS 491621 PLYMOUTH MA $12.77
Arrival Date Departure Date
04/06/18 04/13/18
00000000
LODGING
04/18/18 VZWRLSS*BILL PAY VN FOLSOM CA $320.34
8009220204
TELECOM SVC:PREPAID RECURRING PHONE SER
04/19/18 Verizon Wireless - Prepaid (888)294-6804 FL $53.13
PREPAID
DOMINICK FUCITO
Card Ending 9-93019
Amount
01/25/18 USA TECH-VENDING 41 MALVERN PA $1.05
FAST FOOD RESTAURANT
03/29/18 SHELL OIL 57542576905 CORTLANDT MNR NY $38.61
AUTO FUEL DISPENSER
03/29/18 EXXONMOBIL 9755 BOURNE MA $35.79
508-759-2105
03/30/18 ROYAL GARDEN KINGSTON MA $75.00
USFC02364
03/30/18 WWW.ITUNES.COM/BILL CUPERTINO CA $11.68
DIRECT MKTG INTERNET
03/31/18 ROSE AND VICKIS PLYMOUTH 000000001 PLYMOUTH MA $61.92
5088882822
03/31/18 SAGAMORE BEACH ACE 0000 SAGAMORE BEAC MA $28.53
508-833-4400
04/01/18 Shaws - Osco 2585 PLYMOUTH MA $30.68
GROCERY STORE
04/02/18 THE HOME DEPOT #2613 WAREHAM MA $105.04
800-654-0688
04/02/18 BOURNE DENTAL ASSOC. LLC 000000001 BOURNE MA $99.00
5087592724
04/04/18 7-ELEVEN 32482 00073248201 PLYMOUTH MA $53.78
508-224-3555
04/05/18 SHELL OIL 57542576905 CORTLANDT MNR NY $44.78
AUTO FUEL DISPENSER
04/05/18 SHELL OIL 57542576905 CORTLANDT MNR NY $10.64
GAS STATION
04/05/18 DUNKIN #336929 Q35 3369 N SCITUATE RI $5.27
401-727-1380
04/06/18 EAST BAY GRILLE AT PINEHI 650000009160 PLYMOUTH MA $90.35
5082093000
04/07/18 BIG LOTS PLYMOUTH MA $213.49
6142310065
DISCOUNT STORES
04/08/18 WWW.ITUNES.COM/BILL CUPERTINO CA $9.99
DIRECT MKTG INTERNET

Continued on next page

 Premier Rewards Gold Card p. 5/10

PATSY DEMARCO FUCITO

Closing Date 04/27/18 Account Ending 9-97002

Detail Continued *Indicates posting date

Amount
04/10/18 Shaws - Osco 2585 PLYMOUTH MA $28.84
GROCERY STORE
04/10/18 BOURNE DENTAL ASSOC. LLC 000000001 BOURNE MA $462.00
5087592724
04/10/18 EXXONMOBIL 9754 PLYMOUTH MA $59.86
508-888-7022
04/12/18 SHELL OIL 57542576905 CORTLANDT MNR NY $49.51
AUTO FUEL DISPENSER
04/12/18 SHELL OIL 57542576905 CORTLANDT MNR NY $12.70
GAS STATION
04/14/18 GOOGLE *DOMAINS G.CO/HELPPAY# CA $10.62
PYMT SERVICE
04/14/18 LOWE'S WAREHAM MA $64.85
774-678-6000
04/14/18 STAPLES 01275 WAREHAM MA $395.71
01275000120647 02571
POPPIN MOUSEPAD AQUA
LED GOOSENECK DESK LAMP BLACK
04/15/18 CBD*USTECHSUPPORT 866-981-1005 CA $19.99
866-981-1005
04/19/18 SHELL OIL 57542576905 CORTLANDT MNR NY $33.62
AUTO FUEL DISPENSER
04/19/18 EXXONMOBIL 9755 BOURNE MA $53.54
508-759-2105
04/20/18 THE HOME DEPOT PLYMOUTH MA $323.73
800-654-0688
04/22/18 SIRIUS XM RADIO INC. 888-635-5144 NY $228.53
RADIO SERVICE
04/22/18 THE HOME DEPOT PLYMOUTH MA $130.35
800-654-0688
04/23/18 THE HOME DEPOT PLYMOUTH MA $93.40
800-654-0688
04/23/18 SUNOCO 0006192910 0006 PLYMOUTH MA $64.56
508-833-9200
04/26/18 SHELL OIL 57542576905 CORTLANDT MNR NY $38.15
AUTO FUEL DISPENSER
04/26/18 VERIZON AGENT FEE 800-922-0204 FL $7.00
PAYMENT FEE
04/26/18 VERIZON WIRELESS IVR 800-922-0204 FL $162.16
BILL PAY
TESS R FUCITO
Card Ending 9-92037 Monthly Spending Limit: $200
Amount

03/29/18 SHELL OIL 10001380004 SAGAMORE BEACH MA $39.62

AUTO FUEL DISPENSER
04/07/18 COURTYARD RESTAURANT 650000006508371 CATAUMET MA $19.25
5085631818
04/09/18 PLYMOUTH HOUSE OF PIZZ 000000001 PLYMOUTH MA $13.75
5087460444
04/10/18 Shaws - Osco 2585 PLYMOUTH MA $5.00
GROCERY STORE

Continued on reverse
 PATSY DEMARCO FUCITO Account Ending 9-97002 p. 6/10

Detail Continued *Indicates posting date

Amount
04/10/18 DUNKIN #301429 Q35 3014 PLYMOUTH MA $2.88
781-279-0290
04/11/18 SUNOCO 0006192910 0006 PLYMOUTH MA $16.15
508-833-9200
04/11/18 DUNKIN #301429 Q35 3014 PLYMOUTH MA $8.67
781-279-0290
ALEXXA F FUCITO
Card Ending 9-92045 Monthly Spending Limit: $200
Amount

04/19/18 SHELL OIL 10001380004 SAGAMORE BEACH MA $39.10

AUTO FUEL DISPENSER
04/22/18 CUMBERLAND FARMS 230/UNBRANDED BUZZARDS BAY MA $33.96
CONVENIENCE
PETER L MARINOS
Card Ending 9-91054
Amount
03/28/18 SUPER PETRO BOURNE BUZZARDS BAY MA $51.11
781-356-1960
03/29/18 VIOC AB1147 AB11 PLYMOUTH MA $114.22
855-846-2457
03/29/18 STOP & SHOP GAS #474/UNBRANDED 0821000 E WAREHAM MA $56.00
FUEL
03/30/18 R AND L AUTO 000912200199422 EAST WAREHAM MA $140.00
EALVESHANOVERMALL@GMAIL.C
04/07/18 PAYPAL *MC HID 4029357733 CA $60.48
402-935-7733
04/07/18 PAYPAL *NEXXTPLUSCO 4029357733 IL $5.99
402-935-7733
04/07/18 PAYPAL *GU JUPING 4029357733 CH $79.00
402-935-7733
04/07/18 PAYPAL *XUMINGHUA 4029357733 CH $7.99
402-935-7733
04/08/18 THE HOME DEPOT #2613 WAREHAM MA $107.15
800-654-0688
04/08/18 ONSET VILLAGE MARKET 0178 ONSET MA $11.00
508-291-1440
04/09/18 SHELL OIL 12525039009 FALMOUTH MA $15.00
AUTO FUEL DISPENSER
04/09/18 SHELL OIL 12525039009 FALMOUTH MA $15.01
AUTO FUEL DISPENSER
04/09/18 DUNKIN #344173 Q35 3441 BUZZARDS BAY MA $3.09
781-279-0290
04/10/18 CVS/PHARMACY #01247 000001247 WAREHAM MA $78.71
8007467287

Fees

Amount
04/22/18 PATSY DEMARCO FUCITO Late Payment Fee $38.00

Total Fees for this Period $38.00

Continued on next page

 Premier Rewards Gold Card p. 7/10

PATSY DEMARCO FUCITO

Closing Date 04/27/18 Account Ending 9-97002

2018 Fees and Interest Totals Year-to-Date

Amount
Total Fees in 2018 $260.00
Total Interest in 2018 $0.00

Interest Charge Calculation

Your Annual Percentage Rate (APR) is the annual interest rate on your account.
Transactions Dated Annual Balance Interest
Percentage Subject to Charge
From To Rate Interest Rate

Select & Pay Later 09/23/2011 19.74% (v) $0.00 $0.00

Promotional Select & Pay Later 11/15/2017 1.99% $0.00 $0.00

Rate Expires 08/28/2018 then will go to 19.74% (v)*
Total $0.00
(v) Variable Rate

* The APR for this balance is a promotional rate and it will expire on the date shown. Any balance at a promotional interest rate that has
not been paid in full by its expiration date will begin accruing interest at the 'go to' APR shown following the expiration date.

Information on Pay Over Time

There is no pre-set spending limit on your Card

No pre-set spending limit does not mean unlimited spending. Purchasing power adjusts with your use of the Card,
your payment history, credit record and financial resources known to us and other factors. Unless you have been
previously notified otherwise, your Card has no pre-set spending limit.

Your Pay Over Time Limit is $35,000.00

We may approve or decline a charge regardless of whether your Card account balance exceeds or does not exceed
your Pay Over Time limit. You must pay in full all charges that are not placed into a Pay Over Time balance. For more
information about Pay Over Time features please visit americanexpress.com/payovertime.

You are currently enrolled in Select & Pay Later

You can select eligible charges to move into your Pay Over Time balance. Each month you simply choose whether to
pay in full, pay the minimum due, or pay any amount in between. Interest applies from the date you add a charge to
your Pay Over Time balance until the date it is paid.

You are currently enrolled in Select & Pay Later

You can select eligible charges to move into your Pay Over Time balance. Each month you simply choose whether to
pay in full, pay the minimum due, or pay any amount in between. Interest applies from the date you add a charge to
your Pay Over Time balance until the date it is paid.

Enrollment in Automatic Flight Insurance

This is a reminder that you are currently enrolled in Automatic Flight Insurance*. This optional insurance product can provide coverage
for accidental death and dismemberment when flying on a covered trip. If you choose to cancel your enrollment or require additional
information regarding your enrollment, please contact us at the number listed on the back of your card.
* Underwritten by AMEX Assurance Company. Terms, conditions, and exclusions apply.
Enrollment in Premium Baggage Protection
This is a reminder that you are currently enrolled in Premium Baggage Protection*. This optional insurance product can provide
primary coverage for lost, stolen, damaged or delayed baggage when traveling on a covered trip. If you choose to cancel your
enrollment or require additional information regarding your enrollment, please contact us at the number listed on the back of your
card.
* Underwritten by AMEX Assurance Company. Terms, conditions, and exclusions apply.

Continued on reverse
PATSY DEMARCO FUCITO Account Ending 9-97002 p. 8/10

Enrollment in Travel Delay Protection

This is a reminder that you are currently enrolled in Travel Delay Protection*. This optional insurance product can provide secondary
coverage for expense reimbursement for hotel, transportation, food and necessities when experiencing a qualifying delay on a
covered trip. If you choose to cancel your enrollment or require additional information regarding your enrollment, please contact us at
the number listed on the back of your card.
* Underwritten by AMEX Assurance Company. Terms, conditions, and exclusions apply.
Enrollment in Premium Car Rental Protection
This is a reminder that you are currently enrolled in Premium Car Rental Protection*. This optional insurance product can provide
primary coverage for theft and damage, accidental death and dismemberment, and excess coverage for medical bills and personal
property when renting a covered vehicle. Liability coverage is not included. If you choose to cancel your enrollment or require
additional information regarding your enrollment, please contact us at the number listed on the back of your card.
* Underwritten by AMEX Assurance Company. Terms, conditions, and exclusions apply.
 Premier Rewards Gold Card p. 9/10

PATSY DEMARCO FUCITO

Closing Date 04/27/18 Account Ending 9-97002

Travel Insurance Premium Refund/Credit Form

In this billing statement, you have been billed one or more premiums for optional insurance products in which you are currently enrolled.
There may be occasions when you are billed premiums based on charges that are not covered by your insurance products.

If you have been charged an insurance premium for one of the reasons listed below, you should request a refund. To do so, you can call us,
complete the online refund request form, or complete the form below and include it with payment of your bill. You can subtract the total
premium refund amount from your new balance. If you do not fill out this form completely, your request may be delayed or denied.
If we deny your request, you will be responsible for paying your total balance in full.

Please see the back of this form if requesting refunds for TravelAssure or TravelAssure Classic and for additional information on
requesting a refund.

Reasons for Refund/Credit:

A. Non-fare airline services charges (e.g. excess baggage, itinerary charges, upgrade, or any other non-air transportation charges)
B. Unused airline tickets or cancelled trips (only select this option if the airline will not be providing a refund to your American Express
account for the cancelled trip)
C. Non-scheduled airline flights (e.g. private jet)
D. Two or more insurance premiums charged for same car rental
E. Car rental no-show
F. Other charges unrelated to actual car rental (e.g. gas)
G. Car rental in an excluded country (i.e. Australia, Ireland, Israel, Italy, Jamaica, and New Zealand)
H. A vehicle other than a rental car
I. Insurance coverage required by a car rental company

If you believe you are eligible for a refund for any other reason, or if you have questions, please call the number on the back of your Card
to speak with a Customer Care Professional.

Please detach here

Airline or Car Ticket/ Airline Ticket or Month Reason Insurance Amount of Insurance
Rental Company Rental Car Rental Billed for Product Premium Refund
Name Amount Agreement Number Refund Requested

"Sample Airlines" $374.20 0012351230912 March B Travel Delay $9.95

Additional space is available on the reverse side of this form.

499913403758150427 Account Ending: 9-97002
 PATSY DEMARCO FUCITO Account Ending 9-97002 p. 10/10

Additional information to assist you in completing the refund form

Ways to request If you have questions or do not wish to request your refund by submitting this form, you may call the number on the
a refund back of your Card or fill out the refund coupon available with your online billing statement. For additional information
on requesting your refund online, please visit americanexpress.com/insurancerefund.

Please do not fill this form out if you expect a credit to your Card account for your airline ticket charge. You will
automatically receive a refund once your ticket is credited on your American Express account. Refunds will appear as
Requesting credits on your monthly statement.
a refund
If you do not expect a credit for your airline ticket charge, fill out this refund form completely and return the
form with your payment. Please deduct the total premium refund amount from your new balance.

If you are requesting a refund for TravelAssure or TravelAssure Classic, follow the previous instructions and use
the information below to determine the amount of the refund you should request:

If you cancelled an airline ticket but will not receive a credit to your Card account for your airline ticket charge you're
entitled to a partial * premium refund as follows:

· For TravelAssure, which has an insurance premium of $28.95, you are eligible for a partial refund in the amount
TravelAssure of $10. Please deduct this amount from your new balance for each insurance premium charge eligible for
and refund.
TravelAssure
Classic · For TravelAssure Classic, which has an insurance premium of $19.95, you are eligible for a partial refund in the
amount of $8. Please deduct this amount from your new balance for each insurance premium charge eligible
for refund.

If you are requesting a refund for a different eligible reason, you should request a refund for the full insurance
premium amount that was billed.

* TravelAssure and TravelAssure Classic can provide coverage for Trip Cancellation as well as other types of coverage.
When requesting a refund due to a cancelled trip, please note that a refund will not be granted for the portion of
the premium associated with Trip Cancellation, since that coverage already will have already gone into effect.
You'll receive a partial refund of $10 per TravelAssure and $8 per TravelAssure Classic charge for the portion of the
premium not related Trip Cancellation coverage. You can still submit claims to recover nonrefundable trip costs.

Airline or Car Ticket/ Airline Ticket or Month Reason Insurance Amount of Insurance
Rental Company Rental Car Rental Billed for Product Premium Refund
Name Amount Agreement Number Refund Requested

If you require additional space, please make a copy of this form and return both with your payment.
499913403758150427 Account Ending: 9-97002