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Please Print * Policy . Name of Tosnred Doornating 5 ° No , i 3 : PERSONAL ACCIDENT AND SICKNESS |Uxcorcs: , Pre ; Insured Only Premium $ ‘ ZIP 7 . Dependent Premium $4. @O© _ {City Pry And Siate Ore . - TOTAL PREMIUM $ , e | BAGGAGE AND PERSONAL EFFECTS g_ AOKL- Amount of Insurance eee 8 Effective at: cose vist. Sgncginiz 4 COMBINED , a.m. ~jVef-- ‘ q PREMIUM $ Hour 748 p-m. pae_Ll-OE-?2/ ~ a Term of Coverage: Month Day Year ‘ ; - pee YOU Personal Sionz _- ‘ AGE = -; — i sore Tecmo t Ce ee = - —_ oe ome arte “Plaave Print se ee eat — _' . "7 Policy ra “ fr) - r * mye te awed. Number A 0599 16 nes ~ ; PERSONAL ACCIDENT WITH Aegpetegs eae | DOUBLE PROTECTION ON eee | | SCHEDULED AIRLINES . Amount of Insurance: = 7 OO Cana Sn Seretued A) ea So Lea Sate .* “Fg Principal Sum they } . | Ro PREMIUM $.4f- 29 | Name of Beneficial -© aoe | BAGGAGE, AND PERSONAL EFFECTS | Address of Benefid : ae S wef f° 3 —=——__ Amount of Insurance; | me wt “abe 5 PREMIUM $272 x2. [City ees | Effective: at: : ; . ele | COMBINED PREMIUM $25 ©.) - Me LI~DQ4E-T/ Sol te - 4 Term of Coverage: _!/O pays : - , Month Day ; : | Tees te «| Countersigted-by --. . - DB Cooper-5444 aes ft