BASE BENEFITS 1605

Citicorp Insurance Services, Inc. P.O. Box 901024 Fort Worth, Texas 76101-2424

Reference Number

Instructions for Completing Citi Price Rewind Claim In order for us to process your claim quickly, please read and follow instructions listed below.

1. Please complete this claim form; sign it and either fax it to 1-817-820-5917 or mail to: Citicorp Insurance Services, Inc., P.O. Box 901024, Ft. Worth, TX 76101-2424 with all required documents NO LATER THAN 180 DAYS from the date of purchase. A delay or denial of your claim may result if the completed claim form is not received within 180 days from the date of purchase. If you cannot obtain all of the requested documents within this timeframe, please send the claim form to us anyway. Please allow 15 days after mailing for processing fully completed claim forms.

2. The following documents are required in order to process your claim form: A) A copy of the itemized receipt for the item purchased.

B) A copy of the merchant's advertisement with the lower price for the same item by the same manufacturer. The advertisement must state;

Item

Effective date of sale (within 60 days of purchase)

Sale price

Model number and model year

Authorized dealer or merchant name (in US only)

All documents must be legible If additional information is required, we will contact you. Please retain a copy of all receipts and documents for your personal records. We appreciate your business and look forward to serving you in the future. For questions or assistance call 1-855-569-7366, Monday through Friday, 9:00 a.m. – 11:00 p.m. ET and Saturday, 8:00 a.m. – 8:00 p.m. ET.

All pages to this claim form must be returned in order to process this claim.

FRAUD NOTICES (Note: None of these fraud notices apply to residents of Oregon or New York.)

Except as Indicated Below: "Any person who, with intent to defraud, knowingly submits an application to or files a claim with an insurance company or other person containing false, incomplete, misleading or deceptive facts, statements or information may be guilty of insurance fraud, which is a crime and subjects such person to civil and criminal penalties that can include fines and confinement in prison." For Arizona Only: "For your protection Arizona law requires the following statement to appear on the form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties." For California Only: "For your protection California law requires the following to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison." For Pennsylvania Only: "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 and subjects such person to criminal and civil penalties."

BASE BENEFITS 1605

Citi Price Rewind Reference Number

General Information – Complete Entire Section (Please Print)Credit card number

Cardmember name Daytime telephone number

Cardmember mailing address (city, state and zip code) Please select whether you would like to receive your refund as a credit on your account statement or a check mailed to the address above. If the refund amount is $25 or less, the payment will be in the form of a statement credit to your Citi

Credit Account noted above. Statement Credit Check

Description of Purchase Manufacturer Model/Serial number Type/Description of item

Date of purchase Purchase price

$

Merchant name

Date of advertisement

Advertised sale price

$

Advertised merchant name

Checklist – For Claims Submission

A copy of the itemized receipt for the item purchased A copy of the merchant's advertisement with the lower price for the same item by the same manufacturer. The advertisement must state;

Item

Effective date of sale (within 60 days of purchase)

Sale price

Model number and model year

Authorized dealer or store name (in US only) Certification I certify the foregoing statements are true and correct to the best of my knowledge and belief, without evasion or reservation. If in fact, the furnished information is false, thereby inducing payment of a claim, and the Provider determines that the incorrect information constitutes an aiding and abetting of the filing of a fraudulent claim, the Provider may furnish the above information to the appropriate state authorities to be used in its discretion as the basis for action authorized under applicable state law. In addition, I agree any statements made on this or any other form found to be false, shall give the Provider the right to void the policy. If additional information is deemed necessary, the Provider may require you to sign an Authorization to Release Information which could delay the processing of your claim. Signature of Cardmember Date signed

Program Underwritten by Triton Insurance Company except in New York where it is provided by Citicorp Insurance Services, Inc. (collectively "Provider")