American Express Travel Protection Services
Administered by AIG Claims, Inc. • Plan Policy No. AX-PLAT-70192
STATEMENT OF CLAIM: TRIP DELAY BENEFIT
Dossier Reference: AX-20250218-31008
Generated: Feb 18, 2025
Carrier Code: UA-1842
I. Insured & Common Carrier Incident Particulars
Insured Cardholder
ALEXANDER J. VANCE
Amex Platinum Account
•••• •••••• 31008
Booking / Ticket No.
K79PQR / 016249182301
Common Carrier
United Airlines (UA)
Incident Date & Duration
2025-02-18 (14.5 hours delay)
Hazard Classification
Equipment failure / Mechanical
Carrier Disruption Proof / Memo:
UA Flight 1842 ORD-LGA cancelled due to B737 avionics failure. Rebooked on UA 2104 next morning.
II. Schedule of Itemized Covered Expenses
| # | Date | Category | Merchant / Loss Description | Evidence Provided | Amount (USD) |
|---|---|---|---|---|---|
| Subtotal Itemized Expenses: | $482.40 | ||||
| Less: Carrier Vouchers & Prior Restitutions: | -$0.00 | ||||
| TOTAL REIMBURSABLE CLAIM AMOUNT: | $482.40 | ||||
III. Evidentiary Enclosures Accompanying Claim
✓
Amex Platinum billing statement (Fare charge verified)
✓
Carrier confirmed original booking itinerary
✓
Carrier written cancellation / delay military memo
✓
Complete itemized receipts for all claimed losses
IV. Cardholder Fraud Warning & Certification
I hereby certify under penalty of perjury that the statements, receipts, and documents submitted in connection with this claim are true, correct, and complete to the best of my knowledge. I have not received, nor do I expect to receive, compensation for these expenses from any other insurance or carrier source, except as expressly disclosed above. I authorize American Express Travel Protection Services and AIG Claims, Inc. to obtain from common carriers, hotels, and merchants any records necessary to verify this claim.
Cardholder Electronic Attestation:
/s/ ALEXANDER J. VANCE
Date Executed:
2025-02-18
Direct Claimant Reimbursement Route:
Credit to Amex Statement (Card ending 31008)