AMERICAN EXPRESS

AMEX ASSURANCE COMPANY

PO BOX 981553
EL PASO TX 79998-9920

TOLL FREE FAX (800) 858-5971

July 6, 2016
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RE: Product:
Extended Warranty
Claim Number: 0010115744
Incident Date: July 5, 2016
Dear BERNICE C ROGERS:
Thank you for submitting your Extended Warranty claim. In order to continue processing your
claim, we need you to provide Proof of Loss documentation as described below.

What documentation do we need from you?

Itemized Store Receipt(s)
Repair Estimate from an authorized facility per the Original MFG Warranty. Please contact
your MFG for a list of Authorized Repair facilities.
Complete Information on the Claim Form
What to include with your documentation?
Please include on all pieces of documentation:
Full Name
Claim number
In addition, please keep copies and record the date you sent the documentation to us.

Where do I send my documents?

Please fax or mail this information to us as soon as possible:
Fax: 800-858-5971
Mail: American Express, AMEX Assurance Company, PO Box 981553, El Paso, TX
79998-9920

If you have already sent in the requested documentation above, please disregard this request.
Once all of the requested documentation has been provided by you, we will be able to process
your claim. For your convenience, you can check the status of your claim anytime online at
americanexpress.com/onlineclaim.

Important information about your Claim:

Please refer to your plan documents for additional details, eligibility, and exclusions. Your plan
documents can be found at americanexpress.com/benefitsguide or by calling the Extended
Warranty Claims Department at (800) 225-3750. Additionally, here are other important things to
know about your claim:
Now that you have filed a claim, you must provide us with satisfactory Proof of Loss
documents, or your claim may not be eligible based on the plan documents that were
provided to you.
We reserve the right to request all of the information/documentation we deem necessary to
determine if your claim is eligible.
We will not consider that we have received satisfactory Proof of Loss until the
information we have requested is received.
No payment will be made on claims not substantiated in the manner required by us.
It is your responsibility to provide all required documentation we request. You may be
required to send in the damaged property for further evaluation of your claim or your
claim may not be eligible based on the plan documents that were provided to you.
If any loss under this Policy is insured under any other valid and collectible policy, then
this Policy is in excess of the amount of such other insurance which is payable or paid.
We are here to help
At AMEX Assurance Company, we are committed to providing you the best possible benefit
experience. If you have any questions or need any additional information about your claim,
please call the Extended Warranty Claims Department at (800) 225-3750, and we will be
happy to assist you. Thank you for your Card Membership.
Any person who knowingly and with intent to injure, defraud or deceive any insurance
company, files a statement of claim containing any false, incomplete or misleading information
is guilty of insurance fraud.
Please be advised that there may be an applicable statute of limitations that may bar your rights
in the future. Please refer to your Certificate/Description of Coverage for details.
Sincerely,
Claims Department
AMEX Assurance Company

Eligible Consumer & OPEN Cards:

Extended Warranty is underwritten by AMEX Assurance Company, Administrative Office, Phoenix, AZ under Policy AX0953, Policy
AX0954, Policy EW-AX0958, or Policy EW-IND. For residents of GU and MP, the Plan is underwritten by Tokio Marine Pacific Insurance
Limited, Hagatna, Guam under Policy CRCB000000104. This benefit is not available to residents of American Samoa, Federated States of
Micronesia, Marshall Islands, Palau, and the US Minor Outlying Islands. Coverage is determined by the terms, conditions, and exclusions of the
Policies applicable to your Card and is subject to change with notice. This document does not supplement or replace the Policy.

American Express
AMEX Assurance Company
PO Box 981553
El Paso TX 79998-9920
Phone: Extended Warranty (800) 225-3750 Fax: (800) 858-5971

Extended Warranty Claim Form

0010115744
Claim Number
Instructions: Please complete and sign the Claim Form and send it along with any other
requested documentation to the address or fax number above.
CARD MEMBER INFORMATION:

American Express Card Account Number

used to purchase the item:

Card Member's
Name:
Address:
City:

State:
Primary Phone Number:
Email:

PURCHASE INFORMATION:
Manufacturer:
Item:
Model:
Color/Size/Material:
Merchant:
Date of Purchase:
Item Amount:
Charge Amount:
Duration of original manufacturers warranty period:
Did you purchase an extended service contract for this item?:
Yes
If so, what was the duration of the purchased service contract:
LOSS INFORMATION:
Type of Loss:
Accidental Damage
Defective
Date of Loss:
City, State, and Country where loss occurred:
Please Describe in detail the accidental damage or defect:

Zip:

No

Extended Warranty is underwritten by AMEX Assurance Company, Administrative Office, Phoenix, AZ under Policy AX0953, Policy
AX0954, Policy EW- AX0958, or Policy EW-IND. For residents of GU and MP, the Plan is underwritten by Tokio Marine Pacific Insurance
Limited, Hagatna, Guam under Policy CRCB000000104. This benefit is not available to residents of American Samoa, Federated States of
Micronesia, Marshall Islands, Palau, and the US Minor Outlying Islands. Coverage is determined by the terms, conditions, and exclusions of the
Policies applicable to your Card and is subject to change with notice. This document does not supplement or replace the Policy. Extended
Warranty can extend the terms of the original manufacturer's warranty on warranties of five years or less. We match the length of the original
warranty if the original manufacturers warranty is less than one year, and we provide one additional year if the original manufacturers
warranty is between one year and five years. For Centurion Members, we match the length of the original warranty if the original
manufacturers warranty is less than three years, and we provide three additional years if the original manufacturers warranty is between three
years and five years. Shipping and handling costs for the purchase will not be refunded. Certain purchases are not covered, e.g. items with
physical damage, damage as a result of natural disaster, software, motorized devices and vehicles and their parts. Other important exclusions
apply. You will only be covered up to the amount charged on your eligible Card; coverage is limited up to a maximum of USD $10,000 per
occurrence; not to exceed USD $50,000 per Card Member account per calendar year. You may be required to send the purchased item to us,
in which case we will reimburse you for that shipping cost. This product is in excess of other warranty plans that you have in place for the
eligible item. To be eligible for claim payment, your account must be in good standing on the eligible card that maintains the original charge.
For
full
Terms
and
Conditions,
see
americanexpress.com/EWterms
or
americanexpress.com/CenturionEWterms
or
americanexpress.com/BusinessCenturionEWterms.

ADDITIONAL INFORMATION:
Please refer to your Description of Coverage for complete benefits information. Below is
some information about the claim you are filing:
1. Benefits are not payable if the loss for which coverage is sought was directly or
indirectly, wholly or partially, contributed to or caused by any physical damage,
including, but not limited to, damage as a direct result of natural disaster or a power
surge, except to the extent the original manufacturer's warranty covers such damage.
2. Extended Warranty does not reimburse for shipping and handling expenses or
installation, assembly, professional advice, maintenance or other service charges.
3. If other insurance is available to you, which provides the same or similar coverage as
that provided by this plan, this plan becomes excess.
4. Motorized devices and their parts which are permanent additions or fixtures to a
residential or commercial building are not eligible for coverage.
PLEASE READ THE INFORMATION BELOW AND SIGN THIS FORM PRIOR TO SUBMISSION.

I UNDERSTAND THAT ANY PERSON WHO KNOWINGLY AND WITH THE INTENT
TO INJURE, DEFRAUD OR DECEIVE ANY INSURANCE COMPANY, FILES A
STATEMENT OF CLAIM CONTAINING ANY
FALSE, INCOMPLETE OR
MISLEADING INFORMATION IS GUILTY OF INSURANCE FRAUD. 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.
Card Member's Signature (required)

Date

Claimant's Signature (if not Card Member)

Date

Any person who knowingly and with intent to injure, defraud or deceive any insurance
company, files a statement of claim containing any false, incomplete or misleading information
is guilty of insurance fraud.
Please be advised that there may be an applicable statute of limitations that may bar your rights
in the future. Please refer to your Certificate/Description of Coverage for details.

AMEX Assurance Company Repair Estimate Form

Customer Information (to be completed by Card Member)
AMEX Assurance Company Claim Number: 0010115744
Customer Name:
Date:
Home Phone Number:
Cell Phone/Other Number:
Address:
Email Address:
Date item was dispensed/delivered (if not
on date of purchase):

Date item was purchased:

Warranty Status: Is your item under a
Manufacturers Warranty?
(Circle)
Yes or No

Is the item claimed used for resale,

professional or commercial use?
(Circle)
Yes or No
This repair estimate form will need to be completed by an Authorized Repair Facility per
the Original Manufacturers Warranty. Please contact your Manufacturer for a list of
Authorized Repair Facilities and submit to us, along with any additional documentation
that was requested. * Failure to use an authorized facility may result in the denial of the
benefits for this claim.
*** Below section should be completed by authorized repair facility/technician ***
Service Diagnosis: (diagnostic fee incurred will be reimbursed regardless of the outcome
of claim)
Model Number:
Serial Number:
Service Date:
Company Name:
Technician:
Address:
Company Phone Number:
Does this item have Physical Damage?
(Circle)
Have these repairs been completed?
(Circle)
Was the item opened during the diagnostic process
by the technician at the authorized repair facility?
(Circle)
Service Diagnosis/Parts Needed:
Comments:

Trip/Diagnostic $ Parts $

Technicians Signature:

Labor $

Other Fees $

Date:

Yes or No
Yes or No
Yes or No

Tax $

Total $

Any person who knowingly and with intent to injure, defraud or deceive any insurance
company, files a statement of claim containing any false, incomplete or misleading information
is guilty of insurance fraud.
Please be advised that there may be an applicable statute of limitations that may bar your rights
in the future. Please refer to your Certificate/Description of Coverage for details.

Extended Warranty is underwritten by AMEX Assurance Company, Administrative Office, Phoenix, AZ under Policy AX0953, Policy
AX0954, Policy EW- AX0958, or Policy EW-IND. For residents of GU and MP, the Plan is underwritten by Tokio Marine Pacific Insurance
Limited, Hagatna, Guam under Policy CRCB000000104. This benefit is not available to residents of American Samoa, Federated States of
Micronesia, Marshall Islands, Palau, and the US Minor Outlying Islands. Coverage is determined by the terms, conditions, and exclusions of the
Policies applicable to your Card and is subject to change with notice. This document does not supplement or replace the Policy. Extended
Warranty can extend the terms of the original manufacturer's warranty on warranties of five years or less. We match the length of the original
warranty if the original manufacturers warranty is less than one year, and we provide one additional year if the original manufacturers
warranty is between one year and five years. For Centurion Members, we match the length of the original warranty if the original
manufacturers warranty is less than three years, and we provide three additional years if the original manufacturers warranty is between three
years and five years. Shipping and handling costs for the purchase will not be refunded. Certain purchases are not covered, e.g. items with
physical damage, damage as a result of natural disaster, software, motorized devices and vehicles and their parts. Other important exclusions
apply. You will only be covered up to the amount charged on your eligible Card; coverage is limited up to a maximum of USD $10,000 per
occurrence; not to exceed USD $50,000 per Card Member account per calendar year. You may be required to send the purchased item to us,
in which case we will reimburse you for that shipping cost. This product is in excess of other warranty plans that you have in place for the
eligible item. To be eligible for claim payment, your account must be in good standing on the eligible card that maintains the original charge.
For
full
Terms
and
Conditions,
see
americanexpress.com/EWterms
or
americanexpress.com/CenturionEWterms
or
americanexpress.com/BusinessCenturionEWterms.