◆ SpookStack

Plesse Print ha) “PERSONAL, ACCIDENT. . ‘DOUBLE PROTECTION ON: * SCHEDULED AIRLINES Amount 6 en Suri (ScheduledAir) | $ Principal Sum’ (Qther’ Ac), 2 ie PREMIUM, $22.50 Month PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON — SCHEDULED AIRLINES * nsurance: Addres -. J of Insu Amount 0 $68-$99 Capital Sum (Scheduled Air) on eT lay State (4 | nC : ST | m (Other Ace.) PREMIUM st eg ae) Name of Beneficiary BAGGAGE AND PERSONAL EFFECTS | Address of Beneficiary $ Amount of Insurance - PREMIUM $ Effective at: _ Hour tie BS me COMBINED PREMIUM $ Term of Coverage: Month Personal Signat Of Insured - b6 b7C “ Day - "Year - b6 b7C zip Code “VU Day Year » DB Cooper-5435