◆ SpookStack

Numer A_058911 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES - Amount of Insurance: sd Capital Sum (Scheduled Air Principal Sum (Qther Ace. PREMIUM $ BAGG/ . AND PERSONAL EFFECTS $ ALLA __ Amount of Wise PREMIUM § Address — Address of Beneficiary F : a —| Effective at: 3 =. - - . ‘ — 2.7. . / ; ° COMBINED PREMIUM $.-—____ “Hour LUAS 7 a= p.m. pate__2= 2 -7/ ot Days . os Month Day Term of Coverage: PERSONAL ACCIDENT AND SICKNESS $ _ Amount of Insuragee Insured Only Premium $ D+ as Dependent Premium $ 2:L5 [City COANCO State LA JERS Code BAGGAGE AND PERSONAL EFFECTS | Address of Benefiaary a NA oO $s JL OKR— Amount of Insurance PREMIUM ¢ ROU Effective at: Hour S60 pm. pae_ Li DE~TF/ COMBINED PREMIUM $ Term of Coverage: 7 ____ Days Licensed Resident Agent