This Description of Coverage for $100,000 Travel Accident Insurance coverage applies to
cards issued through American Express Centurion Bank (AECB).
Cardmembers can identify which Bank issued their Card(s) by accessing their
Cardmember Agreement, Part 1 of 2.
$100,000
TRAVEL ACCIDENT INSURANCE
Underwritten by AMEX Assurance Company
Administrative Office, Green Bay, Wisconsin
DESCRIPTION OF COVERAGE
DEFINITIONS
Accident means a sudden, unexpected, or unintended
event that occurs at a single, identifiable time, and
place which causes Injury and shall also include
exposure resulting from a mishap on a Common
Carrier Conveyance in which the Covered Person is
traveling.
Additional Cardmember means any individual who
has received an American Express Card at the request
of a Basic Cardmember for use in connection with
the Basic Cardmember’s American Express Card
account.
Alighting means when a Covered Person is in the
direct and immediate act of moving down, out, or off
of the Common Carrier Conveyance while on a
Covered Trip. Once the Covered Person’s body has
completely exited the Common Carrier Conveyance,
he or she is no longer Alighting.
American Express Card shall mean, unless
otherwise specified, any of the Cards or accounts,
depending on the type, that provide up to $100,000 of
coverage under Master Policy AX0948.
Basic Cardmember means any individual who has
been issued one or more American Express Cards
and who has an American Express Card account.
Boarding means when a Covered Person is in the
direct and immediate act of getting on and entering
into the Common Carrier Conveyance while on a
Covered Trip.
Common Carrier Conveyance means an air, land or
water vehicle (other than a personal or rental vehicle)
licensed to carry passengers for hire and available to
the public.
Commutation means travel between a person’s
residence, whether temporary or otherwise, and their
routine place of daily employment.
Company means AMEX Assurance Company and
its duly authorized agents.
Covered Person means the Basic Cardmember, each
Additional Cardmember, and each of these
Cardmember’s spouses or Domestic Partners and
dependent children under 23 years of age. All
Covered Persons must have a Permanent Residence
within the 50 United States of America, or the
District of Columbia. All other persons are not
Covered Persons under the Policy.
Covered Trip means a trip taken by the Covered
Person between the point of departure and the final
destination as shown on the Covered Person’s ticket
or verification issued by the Common Carrier
Conveyance, provided the Covered Person’s Entire
Fare for such trip on the Common Carrier
Conveyance involved in the loss has been charged to
a Basic or Additional Cardmember’s eligible
American Express Card account prior to any Injury.
Domestic Partner means a person of the same or
opposite gender who either,
1. can provide documentation of registration of
the Domestic Partner relationship pursuant
to a state, county or municipal provision, or
2. can meet the following qualifications:
a. have resided with each other
continuously for at least 12 months
in a sole-partner relationship that is
intended to be permanent;
b. are not married to any other person;
c. are at least 18 years old;
d. are not related to each other by
blood closer than would bar
marriage per state law; and
e. are financially interdependent as
can be documented by copies of
joint home ownership or lease,
common bank accounts, credit
cards, investments, or insurance.
Entire Fare means the cost of the full fare for a
Covered Trip on a Common Carrier Conveyance that
is charged to the Basic or Additional Cardmember’s
American Express Card and payable in full in U.S.
dollars or combined with American Express
Membership Rewards® Points. Entire Fare does not
include fares on a Common Carrier Conveyance
defrayed in full or in part with Frequent Flyer Miles.
Frequent Flyer Miles means an award of air
transportation, regardless of whether the award is
referenced as frequent flyer miles, voucher, trip pass,
coupon, or other awards, provided to a Covered
Person or for which a Covered Person may benefit
that may be used to pay, in full or in part, or
otherwise defray or reduce the costs of air
transportation.
Injury means bodily injury which:
1. is caused by an Accident which occurs while
the Covered Person’s insurance is in force
under the Policy;
2. results in loss insured by the Policy; and
3. creates a loss due, directly or independently
of all other causes, to such accidental bodily
injury.
Master Policy means the Group Insurance Master
Policy (AX0948 issued to American Express Travel
Related Services Company, Inc.)
Permanent Residence means the Covered Person’s
one primary dwelling place, where the Covered
Person permanently resides.
Policy means the Master Policy and this Description
of Coverage.
We, Us, Our means the Company.
BENEFIT AMOUNTS
As a benefit of Cardmembership, the Covered Person
will receive a benefit level of up to $100,000 of
coverage depending on the type of American Express
Card account to which the Entire Fare for the
Common Carrier Conveyance was charged for the
Covered Trip.
Loss, as used in the Table of Losses chart means:
1. with reference to hand or foot, the complete
and permanent severance through or above
the wrist or ankle joint; and
2. with reference to eye, the irrecoverable loss
of the entire sight of such eye.
$100,000 MAXIMUM INDEMNITY PER
COVERED PERSON
In no event will multiple American Express Cards
obligate the Company to pay for more than one loss
sustained by any one individual Covered Person as a
result of any one Accident. The Company’s
obligation under the Policy will be determined
according to the highest amount payable under the
specific American Express Card actually used to
charge the Entire Fare of the Common Carrier
Conveyance for the Covered Trip.
If the Covered Person is eligible for coverage under
other policies underwritten by AMEX Assurance
Company that also provide a benefit for accidental
death and/or dismemberment, the maximum sum
payable under all applicable policies for an accidental
death and/or dismemberment loss is $3,500,000.
This maximum limit applies regardless of whether or
not the Covered Person is required to enroll under the
policy or is provided coverage as a benefit of
Cardmembership.
This does not preclude the
Covered Person from receiving all entitled benefits
other than accidental death and/or dismemberment
benefits, up to the maximum limit disclosed under
other AMEX Assurance Company policies.
The Company will 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, but only if such loss occurs within 100
days after the date of the Accident which caused the
Injury. Benefits will be paid for the greatest loss. In
no event will the Company pay for more than one
loss sustained by the Covered Person as the result of
any one Accident.
$100,000
$100,000
$100,000
Common Carrier Benefit
This benefit is payable if the Covered Person sustains
accidental death or dismemberment as a result of an
Accident which occurs while riding solely as a
passenger in, or Boarding, or Alighting from, or
being struck by a Common Carrier Conveyance on a
Covered Trip.
$100,000
Exposure and Disappearance
Table of Losses
Dismemberment
Loss of both hands or both feet
Loss of one hand and one foot
Loss of entire sight of both eyes
Loss of entire sight of one
eye and one hand or one foot
$50,000
$50,000
DESCRIPTION OF BENEFITS
You, Your means the Additional Cardmember and
the Basic Cardmember.
Loss of life
Loss of one hand or one foot
Loss of the entire sight of one eye
$100,000
If the Covered Person is unavoidably exposed to the
elements because of an Accident on a Covered Trip
which results in the disappearance, sinking or
wrecking of the Common Carrier Conveyance, and if
as a result of such exposure, the Covered Person
suffers a loss for which benefits are otherwise
payable under the Policy, such loss will be covered
under the Policy.
If the Covered Person disappears because of an
Accident on a Covered Trip which results in the
disappearance, sinking or wrecking of the Common
Carrier Conveyance, and if the Covered Person’s
body has not been found within 52 weeks after the
date of such Accident, it will be presumed, subject to
there being no evidence to the contrary, that the
Covered Person suffered loss of life as a result of
Injury covered by the Policy.
COVERAGE REQUIREMENTS
A Covered Person will be fully insured for benefits
under the Policy while taking a Covered Trip on a
Common Carrier Conveyance only when the Entire
Fare has been charged to an American Express Card.
Eligibility for coverage will remain in effect as long
as the definition of a Covered Person is met.
EXCLUSIONS
This Policy does not cover any loss caused or
contributed to by, directly or indirectly, wholly or
partially:
1. suicide or self-destruction or any attempt
thereat, while sane or insane; intentionally
self-inflicted Injury, suicide or any attempt
thereat, while sane;
2. war or any act of war whether declared or
undeclared; however, any act committed by
an agent of any government, party, or
faction engaged in war, hostilities, or other
warlike operations provided such agent is
acting secretly and not in connection with
any operation of armed forces (whether
military, naval or air forces) in the country
where the Injury occurs shall not be deemed
an act of war;
3. injury to which a contributory cause was the
commission of or attempt to commit an
illegal act by or on behalf of the Covered
Person or his/her beneficiaries;
4. injury received while serving as an operator
or crew member of any conveyance;
5. injury received while driving, riding as a
passenger in, boarding or alighting from a
rental vehicle;
6. injury received during or as a result of
Commutation; or
7. sickness, physical or mental infirmity,
pregnancy, or any medical or surgical
treatment for such conditions, unless
treatment of the condition is required as the
direct result of an Injury.
BENEFICIARY
The Basic Cardmember may designate a beneficiary
or change a previously designated beneficiary for
himself or herself and his or her spouse or Domestic
Partner and dependent children who are not
Additional Cardmembers.
An Additional
Cardmember may designate a beneficiary or change a
previously designated beneficiary for himself or
herself and his or her spouse or Domestic Partner and
dependent children who are not also the Basic
Cardmember, the Basic Cardmember’s spouse or
Domestic partner or children, or Additional
Cardmembers.
No one else may designate or change a previously
designated beneficiary. For such designation or
change to become effective, a written request, on a
form satisfactory to the Company, must be filed with
American Express. Such designation or change will
take effect as of the date it was signed by the Covered
Person, provided it has been received by American
Express, but any payment of proceeds made by the
Company prior to receipt of such designation or
change shall fully discharge the Company to the
extent of such payment.
CLAIM PROVISIONS
Notice of Claim
Notice of claim must be given to AMEX Assurance
Company, Claims Administrative Office, P.O. Box
19020, Green Bay, WI 54307-9020 within 30 days
after the occurrence or commencement of any loss
covered by the Policy, or as soon thereafter as is
reasonably possible. Notice given by or on behalf of
the claimant to the Company at its Administrative
Office, or to any authorized agent of the Company,
with information sufficient to identify the Covered
Person shall be deemed notice to the Company.
Proof of Loss
Proof of Loss must describe both the Accident and
the Injury, and the extent and type of loss. The Proof
of Loss information must be provided on forms
provided by the Company, as well as through
additional means the claimant may use to present a
claim, and may include specific additional
documentation the Company may request, to include,
but not limited to, proof of payment method for the
Common Carrier Conveyance, medical records, and
death certificate. The Company reserves the right to
request all additional information it deems necessary
in order to determine the claim is payable and will
not consider that it has received completed Proof of
Loss until the information it has requested is
received.
Payment of Claims
Benefits for loss of life of a Covered Person will be
paid to the designated beneficiary. Benefits for all
other losses sustained by a Covered Person will be
paid to the Covered Person, if living, otherwise to the
designated beneficiary. If more than one beneficiary
is designated and the Covered Person has failed to
specify the beneficiaries’ respective interests, the
designated beneficiaries shall share equally. If no
beneficiary has been designated, or if the designated
beneficiary does not survive the Covered Person, the
benefits will be paid to the surviving person or
equally to the surviving persons in the first of the
following classes of successive preference
beneficiaries in which there is a living member:
1. spouse or Domestic Partner;
2. children, equally per stirpes; and
3. the estate.
In determining such person or persons, the Company
may rely upon an affidavit by a member of any of the
classes of preference beneficiaries. Payment based
upon any such affidavit shall fully discharge the
Company from all obligations under the Policy
unless, before such payment is made, the Company
has received at its Administrative Office written
notice of a valid claim by some other person. Any
amount payable to a minor may be paid to the
minor’s legal guardian.
TERMINATION or CANCELLATION
Coverage will cease on the earliest of the following:
1. the date the Covered Person no longer maintains
a Permanent Residence in the 50 United States of
America, or the District of Columbia;
2. the date We determine that the Covered Person
or someone on the Covered Persons’
behalf intentionally misrepresented or fraud
occurred;
3. the date the Policy is cancelled;
4. the date the Basic Cardmember’s account ceases
to remain current and in good standing; or
5. the date the Plan is not available in the location
where the Covered Person maintains a
Permanent Residence.
Termination or Cancellation of coverage will not
prejudice any claim originating prior to termination
or cancellation subject to all other terms of the
Policy.
The Company has the right to cancel the Policy at
any time by sending a written notice at least forty
five (45) days in advance to You at Your last known
address. The notice will include the reason for
cancellation.
GENERAL PROVISIONS
Clerical Error
A clerical error made by the Company will not
invalidate insurance otherwise validly in force nor
continue insurance not validly in force.
Conformity with State and Federal Law
If a Policy provision does not conform to applicable
provisions of State or Federal law, the Policy is
hereby amended to comply with such law.
Entire Contract; Representation; Changes
The Description of Coverage, the Master Policy and
any applications, endorsements or riders make up the
entire contract. Any statement You make is a
representation and not a warranty. The Description of
Coverage may be changed at any time by written
agreement between the Master Policyholder and Us.
Only the President, Vice-President or Secretary of
AMEX Assurance Company may change or waive
the provisions of the Description of Coverage. No
agent or other person may change the Description of
Coverage or waive any of its terms. The Description
of Coverage may be changed at any time by
providing notice to You. A copy of the Master Policy
will be maintained and kept by the Master
Policyholder and may be examined at any time.
Fraud
If any request for benefits under the Policy are
determined to be fraudulent, or if any fraudulent
means or devices are used by You or by anyone
acting on Your behalf to obtain benefits, all benefits
will be forfeited.
Legal Actions
No legal action may be brought to recover against the
Policy until 60 days after the Proof of Loss has been
received by the Company. No such action may be
brought after three years, five years for Centurion
Card, Business Centurion CardSM from OPEN: The
Small Business NetworkSM and for residents of
Arkansas; and ten years for residents of Missouri
from the time Proof of Loss is required to be given.
IMPORTANT ADDITIONAL
INFORMATION
The benefits described herein are subject to all of the
terms, conditions, and exclusions of the Policy. This
Description of Coverage replaces any prior
Description of Coverage which may have been
furnished in connection with the Policy. For any
questions regarding the benefits described in this
Description of Coverage, please call 1-800-437-9209,
the number listed on the back of Your Card, or the
number shown on Your Card statement.
IN WITNESS WHEREOF, We have caused this
Description of Coverage to be signed by Our officers:
Joy A. Hanson
President
AMEX Assurance Company
John M. Collins
Secretary
AMEX Assurance Company
Notice to Florida Residents Only: The benefits of the Policy providing Your coverage are governed
primarily by the laws of a state other than Florida.
TAI-DOC 03/07
AMEX ASSURANCE COMPANY
Administrative Office Phoenix, Arizona
ADMINISTRATIVE OFFICE ADDRESS CHANGE ENDORSEMENT
Effective May 1, 2010, your certificate or policy is amended to reflect that Amex Assurance Company’s
Administrative Office is changed to
MC: 080120
20022 N. 31st Avenue
Phoenix, AZ 85027
P.O. Box 53701
Phoenix, AZ 85072-9872
Effective May 1, 2010, your certificate or policy is amended to reflect that Amex Assurance Company’s
Claim Administrative Office is changed to
P.O. Box 981553
El Paso, TX 79998-9920
All other terms of your certificate or policy remain unchanged.
Joy A. Hanson
President
John M. Collins
Secretary
IMPORTANT: This endorsement becomes a part of your certificate or policy. It should be attached to and kept
with your certificate or policy.
MG-ADCHG-END3 04/10
______________________________________________________________________________
Applicable for Residents of the State of Connecticut
The following is hereby added to and made part of the Description of Coverage:
The FRAUD provision is hereby removed in its entirety and replaced with the following:
If any request for benefits under the Policy are determined to be fraudulent, or if any fraudulent means or devices are
used by You or by anyone acting on Your behalf to obtain benefits, all benefits will be forfeited. The Policy cannot
be contested after two (2) years from the effective date of the Description of Coverage.
TAI-RDR1-CT 03/07
______________________________________________________________________________
Applicable for Residents of the State of Illinois
The following is hereby added to and made part of the Description of Coverage:
The definition of Injury is hereby removed from the DEFINITIONS section in its entirety and replaced with the
following:
Injury, for which benefits are provided, means accidental bodily injuries sustained by the Covered Person which are
the direct cause of loss, independent of disease cause of loss, independent of disease or bodily infirmity, and caused
by an Accident occurring while the insurance is in force.
The first paragraph under the EXCLUSIONS section is hereby removed in entirety and replaced with the following:
We will not pay for loss caused by any of the excluded events described below. Loss will be considered to have
been caused by an excluded event if the occurrences of that event directly and solely results in loss, or initiates a
sequence of events that result in loss, regardless of the nature of any intermediate or final event in that sequence.
The following provision is hereby added to the CLAIM PROVISIONS section:
Time of Payment of Claims: Benefits payable under the Policy for any loss other than loss for which the Policy
provides any periodic payment will be paid within 30 days following the Company’s receipt of due written Proof of
Loss.
TAI-RDR1-IL 03/07
______________________________________________________________________________
Applicable for Residents of the State of Indiana
Indiana Residents Only:
Questions regarding your policy should be directed to:
AMEX Assurance Company
800-437-9209
If you (a) need the assistance of the governmental agency that regulates insurance or (b) have a compliant you have
been unable to resolve with your insurer you may contact the Department of Insurance by mail, telephone or email:
State of Indiana Department of insurance
Consumer Services Division
311 West Washington Street, Suite 300
Indianapolis, IN 46204-2787.
Consumer Hotline: 1-800-622-4461. In the Indianapolis Area 1-317-232-2395.
Complaints can be filed electronically at www.in.gov/idoi
_____________________________________________________________________________________________
Applicable for Residents of the State of Kansas
The following is hereby added to and made part of the Description of Coverage:
The following provisions are hereby added to the CLAIM PROVISIONS section:
Claim Forms: The claimant will be furnished with forms for filing Proof of Loss after the Company has received
proper written notice of claim. If the claimant does not get the forms within 15 days, Proof of Loss can be filed
without them. The claimant can send a letter which describes the occurrence, the character and the extent of the loss
for which the claim is made.
Time of Payment of Claims: Benefits payable under the Policy for any loss other than loss for which the Policy
provides any periodic payment will be paid immediately upon the Company’s receipt of due written Proof of Loss.
The LEGAL ACTIONS provision found in the GENERAL PROVISIONS section is hereby removed in its
entirety and replaced with the following:
No legal action may be brought to recover against the Policy until 60 days after the Proof of Loss has been received
by the Company. No such action may be brought after three years, five years for Centurion Card, Business
Centurion CardSM from OPEN: The Small Business NetworkSM and for residents of Arkansas and Kansas; and ten
years for residents of Missouri from the time Proof of Loss is required to be given.
TAI-RDR1-KS 03/07
______________________________________________________________________________
Applicable for Residents of the State of Maine
The following is hereby added to and made part of the Description of Coverage:
The following provisions are hereby added to the CLAIM PROVISIONS section:
Claim Forms: The claimant will be furnished with forms for filing Proof of Loss after the Company has received
proper written notice of claim. If the claimant does not get the forms within 15 days, Proof of Loss can be filed
without them. The claimant can send a letter which describes the occurrence, the character and the extent of the loss
for which the claim is made.
Physical Examination and Autopsy: The Company, at its expense, may examine the Covered Person when, and as
is reasonable, while a claim is pending. The Company may also have an autopsy done where it is not forbidden by
law or belief.
The following is hereby added to the Payment of Claims provision:
All benefits payable under the Policy will be paid within 60 days of receipt of the completed Proof of Loss.
TAI-RDR1-ME 03/07
______________________________________________________________________________
Applicable for Residents of the State of Minnesota
The following is hereby added to and made part of the Description of Coverage:
The following exclusion is hereby removed in its entirety from the EXCLUSIONS section:
injury to which a contributory cause was the commission of or attempt to commit an illegal act by or on
behalf of the Covered Person or his/her beneficiaries;
and replaced with:
injury in which a contributory cause was the commission of or attempt to commit a felony by or on behalf
of the Covered Person or his beneficiaries;
TAI-RDR1-MN 03/07
______________________________________________________________________________
Applicable for Residents of the State of Nevada
The following is hereby added to and made part of the Description of Coverage:
The following item is hereby removed in its entirety from the TERMINATION or CANCELLATION section:
The Company has the right to cancel the Policy at any time by sending a written notice at least forty five (45) days
in advance to You at Your last known address. The notice will include the reason for cancellation.
and replaced with:
The Company has the right to cancel the Policy at any time by sending a written notice at least sixty (60) days in
advance to You at Your last known address. The notice will include the reason for cancellation.
TAI-RDR1-NV 03/07
______________________________________________________________________________________
Applicable for Residents of the State of New Hampshire
This is an accident only policy and it does not pay benefits for loss from sickness. Review your description of
coverage carefully.
Description of Coverage is amended to reflect that Amex Assurance Company’s Administrative Office is changed
to:
AMEX Assurance Company
MC: 080120
20022 N. 31st Avenue
Phoenix, AZ 85027
AMEX Assurance Company
P.O. Box 53701
Phoenix, AZ 85072-9872
(800) 437-9209
The following is hereby added to and made part of the Description of Coverage:
Index of Important Provisions:
Definitions – Page 1
Benefit Amounts – Page 2
Description of Benefits – Page 2
Exclusions – Page 3
Beneficiary – Page 3
Claims Provisions – Page 3
Termination or Cancellation – Page 4
The definition of Covered Person is hereby removed from the DEFINITIONS section in its entirety and replaced
with the following:
“Covered Person means the Basic Cardmember, each Additional Cardmember, and each of these Cardmember’s
spouses (spouse includes person to whom the Insured Person is married or with whom the Insured Person has
entered into a civil union under New Hampshire law) or Domestic Partners and dependent children, by blood or by
law, under 26 years of age (dependent children include: your dependent children under 26 years of age, your
dependent children 26 years or older who because of a handicap condition that occurred before the attainment of the
limiting age, are incapable of self-sustaining employment and dependent upon You for lifetime care and supervision.
Coverage will be extended for as long as such child is incapacitated, and dependent.). All Covered Persons must
have a Permanent Residence within the 50 United States of America, the District of Columbia, Puerto Rico, or the
U.S. Virgin Islands. All other persons are not Covered Persons under the Policy.”
The definition of Domestic Partner, under section 2, items a and e are hereby removed in their entirety.
In the section relating to Exclusions, Exclusion #3 is deleted in it’s entirety and replaced with the following:
“3. Illness, treatment or medical condition arising out of participation in a felony by or on behalf of the Covered
Person and/or his/her beneficiaries;”
The definition of Entire Fare is hereby removed from the DEFINITIONS section in its entirety and replaced with
the following:
“Fare means the cost of the full fare for a Covered Trip on a Common Carrier Conveyance that is charged to the
Basic or Additional Cardmember’s American Express Card and payable in full in U.S. dollars or combined with
American Express Membership Rewards® Points or with Frequent Flyer Miles.”
All references to “Entire Fare” throughout the document are hereby changed to “Fare”
A new section is added after the section relating to Notice of Claims
“Claim Forms
When We receive notice of claim, We will furnish the claimant with forms for filing proof of loss. If the claimant
does not get the forms within 15 days, proof of loss can be filed without them. The claimant must send Us a letter
which describes the Occurrence, the character and the extent of the loss for which the claim is made.”
In the Proof of Loss section, the following paragraph is added:
“We must receive written proof of loss within 90 days after the date of the loss or as soon as is reasonably possible.
Failure to furnish such proof within such time shall not invalidate nor reduce any claim if it shall be shown not to
have been reasonably possible to furnish such proof and that such proof was furnished as soon as was reasonably
possible.
We will pay benefits immediately, within 60 days, upon receipt of Proof of Loss”
In the Payment of Claims section, the last sentence is deleted and replaced with the following:
“If a benefit not exceeding $1,000 is payable to an estate or a minor, We may pay such benefit to any relative by
blood or with a connection by marriage to the Covered Person who is deemed by Us to be entitled. Any payment
We make in good faith shall fully discharge Us to the extent of such payment.”
A new section is added after the section relating to Fraud
“Incontestability
No statement made by a Covered Person can be used in a contest after the Covered Person’s insurance has been in
force two years during his/her lifetime. No statement the Covered Person makes can be used in a contest unless it is
in writing and signed by the Covered Person. This provision shall not preclude the assertion at any time of defenses
related to submission of a false or fraudulent claim based upon provisions in the Policy that exclude or restrict
coverage.”
ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED.
TAI-RDR1-NH-08/10
______________________________________________________________________________
Applicable for Residents of the State of New York
The following is hereby added to and made part of the Description of Coverage:
The definition of Covered Person is hereby removed from the DEFINITIONS section in its entirety and replaced
with the following:
Covered Person means the Basic Cardmember, each Additional Cardmember, and each of these Cardmember’s
spouses or Domestic Partners and dependent children under 23 years of age. All other persons are not Covered
Persons under the Policy.
The definition of Domestic Partner is hereby removed from the DEFINITIONS section in its entirety and replaced
with the following:
"Domestic Partner" means persons of the same or opposite gender who can provide,
1. documentation of registration of the Domestic Partner relationship pursuant to a state, county or municipal
provision; and
2. proof of cohabitation (e.g. a driver's license, tax return, or other sufficient proof); and
3. proof sufficient to establish economic interdependency (e.g., as can be documented by at least two of the
following: proof of joint home ownership, lease, or residence; proof of common bank accounts, credit cards,
investments, joint household or child expenses; proof of joint ownership of major items of personal property).
The definition of Injury is hereby removed from the DEFINITIONS section in its entirety and replaced with the
following:
Injury means bodily injury which:
1. is caused by an Accident which occurs while the Covered Person’s insurance is in force under the Policy;
2. results in loss insured by the Policy;
3. creates a loss due, directly or independently of all other causes, to such accidental bodily injury; and
4. is not received while during or as a result of Commutation.
The EXCLUSION section is hereby removed in its entirety and replaced with the following:
EXCLUSIONS
This Policy does not cover any loss caused or contributed to by, directly or indirectly, wholly or partially:
1.
suicide, attempted suicide or intentionally self-inflicted injury;
2.
war or any act of war, whether declared or undeclared; participation in a felony, riot or insurrection; service in
the Armed Forces or units auxiliary thereto;
3.
Injury in which a contributing cause was the Covered Person's commission of or attempt to commit a felony
or to which a contributing cause was the Covered Person's being engaged in an illegal occupation;
4.
sickness, except for an infection that was the result of an Injury;
5.
mental or emotional disorder;
6.
pregnancy, except complications of pregnancy and except to the extent coverage is required pursuant to
Section 3221 of the New York Insurance Law; or
7.
the consequence of the Covered Person's being intoxicated or under the influence of any narcotic unless
administered on the advice of a Physician.
The following is hereby added to the Proof of Loss provision found in the CLAIMS PROVISIONS section:
Proof of Loss: The Company must receive written proof of Loss at its Administrative Office within 90 days after
the date of the Loss. Failure to furnish such proof within such time shall not invalidate or reduce any claim if it
shall be shown not to have been reasonably possible to furnish such proof within such time, provided such proof was
furnished as soon as reasonably possible. Benefits will be paid within 60 days after the Company receives proper
proof of covered Loss.
The following provision is hereby added to the CLAIM PROVISIONS section:
Claim Forms: The claimant will be furnished with forms for filing Proof of Loss after the Company has received
proper written notice of claim. If the claimant does not get the forms within 15 days, Proof of Loss can be filed
without them. The claimant shall be deemed to have complied with the Proof of Loss requirements upon submitting
within the time fixed a letter which describes the occurrence, the character and the extent of the loss for which the
claim is made.
The following item is hereby removed in its entirety from the TERMINATION or CANCELLATION section:
the date the Covered Person no longer maintains a Permanent Residence in the 50 United States of America, the
District of Columbia, Puerto Rico or the U.S. Virgin Islands;
The following item is hereby removed in its entirety from the TERMINATION or CANCELLATION section:
the date We determine that the Covered Person or someone on the Covered Persons’ behalf intentionally
misrepresented or fraud occurred;
and replaced with:
the date We determine that the Covered Person or someone on the Covered Persons’ behalf intentionally
misrepresented or fraud occurred in a written instrument signed by the Covered Person;
The FRAUD provision is hereby removed in its entirety and replaced with the following:
If any signed written requests for benefits under the Policy are determined to be fraudulent, or if any signed written
fraudulent means or devices are used by You or by anyone acting on Your behalf to obtain benefits, all benefits will
be denied.
TAI-RDR1-NY 03/07
______________________________________________________________________________
Applicable for Residents of the State of North Carolina
The following is hereby added to and made part of the Description of Coverage:
Index of Important Provisions:
Definitions – Page 1
Benefit Amounts – Page 2
Description of Benefits – Page 2
Exclusions – Page 3
Beneficiary – Page 3
Claims Provisions – Page 3
Termination or Cancellation – Page 4
This Certificate of Insurance provides all of the benefits mandated by the North Carolina Insurance Code,
but is issued under a group master policy located in another state and may be governed by that state’s laws.
TAI-RDR1-NC 03/07
______________________________________________________________________________
Applicable for Residents of the State of Oklahoma
Mandatory Endorsement
The following is hereby added to and made part of the Description of Coverage:
Descriptions of Coverage issued in Oklahoma will be governed by the rules and regulations of Oklahoma, not the
Policy.
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes
any claim for the proceeds of an insurance policy containing any false, incomplete or misleading
information is guilty of a felony.
The definition of Domestic Partner is hereby removed from the DEFINITIONS section in its entirety and replaced
with the following:
Domestic Partner means persons who either, can provide documentation of registration of the Domestic Partner
relationship pursuant to a state, county or municipal provision, or can meet the following qualifications: (1) have
resided with each other continuously for at least 12 months in a sole-partner relationship that is intended to be
permanent; (2) are not married to any other person; (3) are at least 18 years old; (4) are not related to each other by
blood; and (5) are financially interdependent as can be documented by copies of joint home ownership or lease,
common bank accounts, credit cards, investments, or insurance.
The following exclusion is hereby removed in its entirety from the EXCLUSIONS section:
war or any act of war whether declared or undeclared; however, any act committed by an agent of any government,
party, or faction engaged in war, hostilities, or other warlike operations provided such agent is acting secretly and
not in connection with any operation of armed forces (whether military, naval or air forces) in the country where the
Injury occurs shall not be deemed an act of war;
and replaced with:
war or act of war, declared or undeclared, while serving in the military service or any auxiliary unit attached thereto;
TAI-RDR1-OK 03/07
______________________________________________________________________________
IMPORTANT NOTICE
FOR TEXAS RESIDENTS
TO OBTAIN IMFORMATION OR MAKE A
COMPLAINT:
AVISO IMPORTANTE
PARA LOS RESIDENTES DE TEXAS
PARA OBTENER INFORMACION
SOMETER UNA QUEJA:
O
PARA
You may call the American Express toll-free telephone
number for information or to make a complaint at:
Usted puede llamar al siguiente numero de telefono
gratis de American Express para informacion o para
someter una queja:
1-800-437-9209
1-800-437-9209
You may also write to:
AMEX Assurance Company
MC: 080120, 20022 N. 31st Avenue
Phoenix, AZ 85027
Usted tambien puede escribir a:
AMEX Assurance Company
MC: 080120, 20022 N. 31st Avenue
Phoenix, AZ 85027
You may contact the Texas Department of Insurance to
obtain information on companies, coverages, rights or
complaints at:
1-800-252-3439
Puede comunicarse con el Departamento de seguros de
Texas para obtener informacion acerca de compania,
coberturas, derechos o quejas al:
1-800-252-3439
You may write the Texas Department of Insurance at:
P.O. Box 149104
Austin, TX 78714-9104
Fax# (512) 475-1771
Web: http://www.tdi.state.tx.us
E-mail: ConsumerProtection@tdi.state.tx.us
Puede escribir al Departamento de seguros de Texas:
P.O. Box 149104
Austin, TX 78714-9104
Fax# (512) 475-1771
Web: http://www.tdi.state.tx.us
E-mail: ConsumerProtection@tdi.state.tx.us
PREMIUM OR CLAIM DISPUTES:
Should you have a dispute concerning your premium or
about a claim you should contact the company first. If
the dispute is not resolved, you may contact the Texas
Department of Insurance.
DISPUTAS SOBRE PRIMAS O RECLAMOS:
Si tiene una disputa concerniente a su prima o a un
reclamo, debe comunicarse con la compania primero.
Si no se resuelve la disputa, puede entonces
comunicarse con el departamento (TDI).
ATTACH THIS NOTICE TO YOUR
DESCRIPTION OF COVERAGE: This notice is for
information only and does not become a part or
condition of the attached document.
NO-TX 03/07
ADJUNTE ESTE AVISO A SU DESCRIPCION
DE COBERTURA: El proposito de este aviso es
proporcionar informacion solamente; no se convierte
en parte o condicion del documento adjunto.
Applicable for Residents of the State of Texas
The following is hereby added to and made part of the Description of Coverage and is applicable only to those
Cardmembers who Permanently Reside in Texas:
The definition of Covered Person is hereby removed from the DEFINITIONS section in its entirety and replaced
with the following:
Covered Person means the Basic Cardmember, each Additional Cardmember, and each of these Cardmember’s
spouses or Domestic Partners and dependent children under 25 years of age (dependent children include:
stepchildren; adopted or a party to a suit to be adopted children; grandchildren who are unmarried and dependent on
the Cardmember for tax purposes at the time the application for coverage is made; and physically or mentally
handicapped children who are unmarried, cannot self-support themselves, and are beyond the termination age). All
Covered Persons must have a Permanent Residence within the 50 United States of America, or the District of
Columbia. All other persons are not Covered Persons under the Policy.
The definition of Domestic Partner is hereby removed the DEFINITIONS section in its entirety and replaced with
the following:
Domestic Partner means a person of the same or opposite gender who can meet the following qualifications:
1. have resided with each other continuously for at least 12 months in a sole-partner relationship that is intended to
be permanent;
2. are not married to any other person;
3. are at least 18 years old;
4. are not related to each other by blood closer than would bar marriage per state law; and
5. are financially interdependent as can be documented by copies of joint home ownership or lease, common bank
accounts, credit cards, investments, or insurance.
TAI-RDR1-TX 03/07
______________________________________________________________________________
Applicable for Residents of the State of Vermont
The following is hereby added to and made part of the Description of Coverage:
All references to Description of Coverage are hereby removed and replaced with Certificate.
All definitions, terms and provisions within this Certificate wherever appearing and denoting a marital relationship
or family relationship arising out of marriage will include parties to a civil union established in the state of Vermont
according to Vermont law and their families.
The definition of Injury is hereby removed from the DEFINITIONS section in its entirety and replaced with the
following:
Injury means bodily injury which:
1. is caused by an Accident which occurs while the Covered Person’s insurance is in force under the Policy;
2. results in loss insured by the Policy; and
3. creates a loss due directly to such accidental bodily injury.
The following exclusion is hereby removed in its entirety from the EXCLUSIONS section:
suicide or self-destruction or any attempt thereat, while sane or insane; intentionally self-inflicted Injury, suicide or
any attempt thereat, while sane;
and replaced with:
suicide or self-destruction or any attempt thereat, while sane; intentionally self-inflicted Injury, suicide or any
attempt thereat, while sane;
The following exclusion is hereby removed in its entirety from the EXCLUSIONS section:
sickness, physical or mental infirmity, pregnancy, or any medical or surgical treatment for such conditions, unless
treatment of the condition is required as the direct result of an Injury.
and replaced with:
sickness, physical infirmity, pregnancy, or any medical or surgical treatment for such conditions, unless treatment of
the condition is required as the direct result of an Injury.
The following hereby replaces the Notice of Claim provision found in the CLAIMS PROVISIONS section:
Notice of claim must be given to AMEX Assurance Company, Claims Administrative Office, P.O. Box 19020,
Green Bay, WI 54307-9020 as soon thereafter as is reasonably possible. Notice given by or on behalf of the
claimant to the Company at its Administrative Office, or to any authorized agent of the Company, with information
sufficient to identify the Covered Person shall be deemed notice to the Company.
TAI-RDR1-VT 03/07
