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Poli . : _ PERSONAL ACCIDENT WITH Address i DOUBLE PROTECTION ON of Insured . SCHEDULED AIRLINES £60,000 Capiatsim Sietucd Ai) oy fy J @ pital Sum (Scheduled Air bn bin) _Stae( Dp Code! $50 DAD Principal Sum (Qyher Acc.) AAD Ados _ PREMIUM $ Name of Beneficia BAGGAGE AND PERSONAL EFFECTS $_(21tne- __ Amount of Insurance PREMIUM $e COMBINED PREMIUM $ Term of Coverage: — 1 4 ‘ . Oe a é i 1 fe 4a Addréss of Insured Numer _ A 058923 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIR INES mount UR nsurance: 5690 Capital Sum (Scheduled Air) low Leas teien Se Dee Sol $¢ SUSE O” Principal Sum ther Ace.) = BAGGAGE AND orl EFFECTS | Address of Beriefic Sma Amount of Insurance PREMIUM § ‘ City State Effective at: COMBINED PREMIUM $. ~ oe" Personal Signature’. - - of Insured - en ———" + AGENT COPY te ge Mie _~ eres |: OE ee ee eer : ‘ o et . . + t ‘ . + Cte agg Ame ee A ETE LO TT YE I A FLARE OY eee he a | Greenman - 4 1