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AL sedadte Leta ete bead _ _ we ne gs: yea - ; os . a ke . y f£ oe - . : : APPLICATION TO MUTUAL OF OMAHA INSURANCE COMPANY, OMAHA, NEBRASKA wes Policy No. T20T t. bE Principal Sum Medica! Benefit $ 5 NONE . 10000 {If the word “None” I appears here, Part C *‘Medical Expense Ben- efits” ig not in effect) Coverages (Insurance is provided under this policy only with respect to those coverages shown below which are followed by the word ‘Yes’ rather than by the word “No”’) - 3. SCHEDULED AIRLINES............ Yes 2, AIRPORT PREMISES; AIRPORT | BUS AND LIMOUSINESERVICE. .:. Yes 3, COMMON CARRIER. ......+4s+10 + LO} Aaddzass of _14, AUTOMOBILE AND OTHER NO SPECIFIED AIRCRAFT.......+.0.- 5. OTHER ACCIDENTS No (NONOCCUPATIONAL) .....-.+-+.+: Co . Agent’s| Policy Date [First Renewal Daté $40.00 No. | 42~24-72 ps ey —_ Amount. me hevecstens oe remium: Mode. .ssectieees Occupation What amount of individual renewable travel accident insurance do you now have with Mutual of Omaha Insurance Company? Issued $...NORC........., ° Pending $... Hone ee City Portlend, State Ore. * (Sertes $490) + ie Le hes te i . ne 7 oe - 7 8 : ee Te te : « 7 a we get f te - 7 rs -_ Sri tig bes Sy ee ae (wR OT