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"_ COMBINED PREMIUM ’$_ | Term of Coverage: AP. = aaa ie - : Amount of Insurance: OQ Capital Sum (Scheduled Air Principal Sus (Other PREMIUM $ - IBAGGAGE AND PERSONAL EFFECTS : aa of AY, id A Si [= SPERS eee 058838" ee Ags = DOUBLE PROTECTION Sa 4 mpeg AIRLIN SNES ess ra Capital Suh. ' (Schaduled:Aie PREMIUM Sum a) her, es} PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES PREMIUM $ COMBINED PREMIUM $ Term of Coverage:- ” Hout = 22 Be Personal Signatu of Insured | e/a TSI Address of Beneficiary _ LIFT yy City — State Effective at: __Hour aT * Date » “Month Day — Year DB Cooper-5434