Flight insurance applications purchased in Portland, 11/23-11/24/71 (enclosure to Portland airtel)
Title revised to match the document’s own text.
Original title: Flight insurance applications purchased at Portland International Airport, 11/23-11/24/71 (enclosure to Portland airtel)
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Id: Cooper-Part-18:099-113
Subject: Cooper Files: Cooper-Part-18:099-113 Document: Flight insurance applications purchased in Portland, 11/23-11/24/71 (enclosure to Portland airtel) Id: Cooper-Part-18:099-113 Page: https://cooper.theunsolved.net/documents/Cooper-Part-18%3A099-113 What is wrong (title, date, type, which pages belong together, copies)? What does the scan show?
A person reads every report. Corrections are made by hand, to the data — titles, dates, names, which pages belong together — never to the scans, and they can take a while to appear.
FBI 164-81, Vault Part 18 pp. 99–113 (DB Cooper-5432–5446), Form — cooper.theunsolved.net/documents/Cooper-Part-18%3A099-113
Policy Number A 058901 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $20,000 Capital Sum (Scheduled Air) $10,000 Principal Sum (Other Acc.) PREMIUM $ 4.25
BAGGAGE AND PERSONAL EFFECTS $[illegible] Amount of Insurance PREMIUM $[illegible]
COMBINED PREMIUM $________ Term of Coverage: 10 Days
Co[illegible] Li[illegible]
--- Right side --- Please Print Name of Insured [redacted] Address of Insured [redacted] City Lake Oswego State Ore ZIP Code [blank] Name of Beneficiary [redacted] Address of Beneficiary [redacted] City [redacted] State [redacted] Code [redacted] Effective at: Noon Hour 12:05 p.m. Date 11 - 23 - 71 Month Day Year Place [illegible] Personal Signature of Insured X AGENT COPY
---
Policy Number A 058899 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $20,000 Capital Sum (Scheduled Air) $10,000 Principal Sum (Other Acc.) PREMIUM $ 4.25
BAGGAGE AND PERSONAL EFFECTS Amount of Insurance [illegible] PREMIUM $ [illegible]
COMBINED PREMIUM $________ Term of Coverage: 10 Days
Co[illegible] Li[illegible]
--- Right side --- Please Print Name of Insured [redacted] Address of Insured [redacted] City Portland State Ore ZIP Code [blank] Name of Beneficiary [redacted] Address of Beneficiary [redacted] City [redacted] State [redacted] Code [redacted] Effective at: Hour 8:25 p.m. Date 11 - 23 - 71 Month Day Year Place PDX Personal Signature of Insured [blank] AGENT COPY
---
b6 b7C
---
DB Cooper-5432
Policy Number A 058895
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $ 20,000 Capital Sum (Scheduled Air) $ 10,000 Principal Sum (Other Acc.) PREMIUM $ 7.75
BAGGAGE AND PERSONAL EFFECTS $ None Amount of Insurance PREMIUM $ [illegible]
COMBINED PREMIUM $________ Term of Coverage: 10 Days
Cou[nter] Lice[nse]
Name of Insured [REDACTED b6/b7C] Address of Insured [REDACTED b6/b7C] City [guess: Beaver] [guess: Fork] State Ore ZIP Code [REDACTED] Name of Beneficiary [REDACTED b6/b7C] Address of Beneficiary [REDACTED b6/b7C] City [illegible] State [illegible] ZIP Code [illegible]
Effective at: Hour 7:30 [X] a.m. p.m. Date 11 - 23 - 71 Month Day Year Place PDX
Personal Signature of Insured [REDACTED b6/b7C]
AGENT CO[PY]
---
Policy Number A 058897
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $ 100,000 Capital Sum (Scheduled Air) $ 50,000 Principal Sum (Other Acc.) PREMIUM $ 7.50
BAGGAGE AND PERSONAL EFFECTS $ NONE Amount of Insurance PREMIUM $ NONE
COMBINED PREMIUM $________ Term of Coverage: _______ Days
Cou[nter] Lice[nse]
Name of Insured [REDACTED b6/b7C] Address of Insured [REDACTED b6/b7C] City [guess: Beaverton] State [guess: Mi] ZIP Code [REDACTED] Name of Beneficiary [REDACTED b6/b7C] Address of Beneficiary [REDACTED b6/b7C] City [illegible] State [illegible] ZIP Code [illegible]
Effective at: Hour 8:00 [X] a.m. p.m. Date 11 - 23 - 71 Month Day Year Place PDX
Personal Sign[ature] of Insured [REDACTED b6/b7C]
AGENT [COPY]
---
DB Cooper-5433
---
b6 b7C
——— Please Print ——— Policy Number A 058898 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $20,000 Capital Sum (Scheduled Air) $10,000 Principal Sum (Other Acc.) PREMIUM $ [guess: 2.15]
BAGGAGE AND PERSONAL EFFECTS $NONE Amount of Insurance PREMIUM $[guess: 4/0/15]
COMBINED PREMIUM $________ Term of Coverage: 10 Days
Name of Insured [REDACTED] b6 Address of Insured [REDACTED] b7C City Portland State Ore ZIP Code Name of Beneficiary [REDACTED] Address of Beneficiary [REDACTED] City [illegible] State [illegible] ZIP Code
Effective at: Hour 8:30 [x] a.m. Date 11 - 23 - 71 ☐ p.m. Month Day Year Place [guess: PDX]
Personal Signature of Insured _______________ AGENT CO[PY]
---
——— Please Print ——— Policy Number A 058900 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $20,000 Capital Sum (Scheduled Air) $[guess: 10],000 Principal Sum (Other Acc.) PREMIUM $ [guess: 2.15]
BAGGAGE AND PERSONAL EFFECTS $NONE Amount of Insurance PREMIUM $NONE
COMBINED PREMIUM $________ Term of Coverage: 10 Days
Co[illegible] Li[illegible]
Na[me] [REDACTED] b6 Address of Insured [REDACTED] b7C City [guess: Milwaukee] State [guess: I mN] Code Name of Beneficiary [REDACTED] Address of Beneficiary [REDACTED] City [illegible] State [illegible] ZIP Code
Effective at: Hour 11:00 [x] a.m. Date 11 - 23 - 71 ☐ p.m. Month Day Year Place [guess: PDX]
Personal Sig[nature] of Insured _______________ AGENT COPY
---
DB Cooper-5434
Policy Number A 059961[illegible trailing digit]
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $20,000 Capital Sum (Scheduled Air) $10,000 Principal Sum (Other Acc.) PREMIUM $2.50
BAGGAGE AND PERSONAL EFFECTS $ [illegible] Amount of Insurance PREMIUM $[illegible]
COMBINED PREMIUM $[illegible] Term of Coverage: 14 Days
Name [redacted] Address of Insured [redacted] City [illegible] State [illegible] ZIP Code [illegible] Name of Beneficiary [redacted] Address of Beneficiary [redacted] City [illegible] State W[illegible] Code [illegible]
Effective at: Hour 9:00 p.m. Date 11 23 71 Month Day Year Place PDX
Personal Signature of Insured [redacted] AGENT COPY
---
Policy Number A 059963
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $[guess: 60],000 Capital Sum (Scheduled Air) $[guess: 20],000 Principal Sum (Other Acc.) PREMIUM $ [guess: 5.25]
BAGGAGE AND PERSONAL EFFECTS $ N AM[illegible] Amount of Insurance PREMIUM $ N [illegible]
COMBINED PREMIUM $[illegible] Term of Coverage: 3 Days
Name [redacted] Address of Insured [redacted] City [illegible] [guess: 2nd] State O[illegible] ZIP Code [illegible] Name of Beneficiary [redacted] Address of Beneficiary [guess: Sandra] [illegible] City [illegible] State [illegible] ZIP Code [illegible]
Effective at: Hour 7:45 p.m. Date 11 23 71 Month Day Year Place PDX
Personal Signature of Insured [redacted] AGENT COPY
---
b6 b7C
---
DB Cooper-5435
Policy Number A 059964
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $ 60,000 Capital Sum (Scheduled Air) $ 30,000 Principal Sum (Other Acc.) PREMIUM $ 2.00
BAGGAGE AND PERSONAL EFFECTS $ none Amount of Insurance PREMIUM $ none
COMBINED PREMIUM $________ Term of Coverage: ______ Days
Countersigned by _______________ Li___________________________
--- Right Side --- —Please Print— Name of Insured [REDACTED b6/b7C] Address of Insured [REDACTED b6/b7C] City Salem State Ore ZIP Code [REDACTED] Name of Beneficiary [REDACTED b6/b7C] Address of Beneficiary SAME City ________ State ________ ZIP Code ________
Effective at: Hour 3:45 ☐ a.m. ☒ p.m. Date 11/23/71 Month Day Year Place PDX
Personal Signature of Insured [REDACTED b6/b7C]
AGENT COPY
---
Policy Number A 058923
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $ [guess: 106,000] Capital Sum (Scheduled Air) $ [guess: 59,000] Principal Sum (Other Acc.) PREMIUM $ [guess: 11.25]
BAGGAGE AND PERSONAL EFFECTS $ none Amount of Insurance PREMIUM $ None
COMBINED PREMIUM $________ Term of Coverage: ______ Days
Countersigned by _______________
--- Right Side --- —Please Print— Na[me of Insured] [REDACTED b6/b7C] Occupation [REDACTED b6/b7C] Address of Insured [REDACTED b6/b7C] City Longview State Ore ZIP Code [REDACTED] Name of Beneficiary [REDACTED b6/b7C] Address of Beneficiary Same City ________ State ________ ZIP Code ________
Effective at: Hour [guess: 4:36] ☐ a.m. ☒ p.m. Date [guess: 11]/23/71
Pl[ace] _______________
Personal Signature of Insured _______________
AGENT COPY DB Cooper-5436
Policy Number A 058887 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $ 20,000 Capital Sum (Scheduled Air) $ 10,00 0 Principal Sum (Other Acc.) PREMIUM $ 3.25
BAGGAGE AND PERSONAL EFFECTS $ [illegible] Amount of Insurance PREMIUM $ [illegible]
COMBINED PREMIUM $________ Term of Coverage: 6 Days
Countersigned by [illegible]
--- Please Print --- Name of Insured [REDACTED b6/b7C] Address of Insured [REDACTED b6/b7C]
City PORTLAND State Ore ZIP Code [blank]
Name of Beneficiary [REDACTED b6/b7C] Address of Beneficiary City [guess: Milwaukie] State Ore ZIP Code [blank]
Effective at: Hour 6:00 p.m. Date 11 23 71 Month Day Year Place PDX
Personal Signature of Insured [REDACTED] AGENT COPY
---
Policy Number A 058888 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $ [guess: 46,000] Capital Sum (Scheduled Air) $ [guess: 23,000] Principal Sum (Other Acc.) PREMIUM $ 6.50
BAGGAGE AND PERSONAL EFFECTS $ 200 Amount of Insurance PREMIUM $ 3.10
COMBINED PREMIUM $ 9.66 Term of Coverage: 6 Days
Countersigned by [illegible] Licensed Resident Agent [illegible]
[REDACTED b6/b7C] Occupation [REDACTED b6/b7C] of Insured [REDACTED b6/b7C]
City [guess: Port[illegible]] /2p1 State Ore ZIP Code [blank]
Name of Beneficiary [REDACTED b6/b7C] Address of Beneficiary [REDACTED b6/b7C] City -- State [blank] ZIP Code [blank]
Effective at: Hour 6:06 p.m. Date 11 23 71 Month Day Year Place PDX
Personal Signature of Insured [REDACTED] AGENT
---
b6 b7C
---
DB Cooper-5437
Policy Number A 059966 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $ 40,000 Capital Sum (Scheduled Air) $ 20,000 Principal Sum (Other Acc.) PREMIUM $ 9.50
BAGGAGE AND PERSONAL EFFECTS $ none Amount of Insurance PREMIUM $ none
COMBINED PREMIUM $____ Term of Coverage: 10 Days
Countersigned by [blank] Li[cense]
Name of Ins[ured]: [redacted] Address of Insured: [redacted] City Vancouver State Wn. Code [blank] Name of Beneficiary: [redacted] Address of Benefici[ary]: [redacted] City [blank] State [blank] ZIP Code [blank] SAME Effective at: Hour 8:30 ☐ a.m. ☒ p.m. Date 11/23/71 Month Day Year Place PDX Personal Signature of Insured: [redacted] AGENT CO[PY]
---
Policy Number A 059967 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $ 100,000 Capital Sum (Scheduled Air) $ 50,000 Principal Sum (Other Acc.) PREMIUM $ [guess: 11.25]
BAGGAGE AND PERSONAL EFFECTS $ none Amount of Insurance PREMIUM $ none
COMBINED PREMIUM $____ Term of Coverage: 4 Days
Countersigned by [blank] Li[cense]
Name of [Insured]: [redacted] Address of Insur[ed]: [redacted] City Pendleton State Ore Code [blank] Name of Beneficiary: [redacted] Address of Beneficiary: SAME City [blank] State [blank] ZIP Code [blank] Effective at: Hour 9:50 ☐ a.m. ☒ p.m. Date 11/23/71 Month Day Year Place PDX Personal Signature of Insured: [redacted] AGENT CO[PY]
---
DB Cooper-5438
---
b6 b7C
Policy Number A 059968
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $ 60,000 Capital Sum (Scheduled Air) $ 30,000 Principal Sum (Other Acc.) PREMIUM $ 6.75
BAGGAGE AND PERSONAL EFFECTS $ none Amount of Insurance PREMIUM $ none
COMBINED PREMIUM $ ____ Term of Coverage: ____ Days
Countersigned by __________ Lice[nsed] __________
Name of [REDACTED b6/b7C] Address of Insured [REDACTED] City [guess: Tacoma] State Wn. Code ___ Name of Beneficiary [REDACTED] Address of Beneficiary ___ City Aberdeen State Wn. Code ___
Effective at: Hour 11:10 p.m. Date 11/23/71 Month Day Year Place PDX
Personal Signature of Insured [signature present]
AGENT COPY
---
Policy Number A 059969
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $ 60,000 Capital Sum (Scheduled Air) $ 30,000 Principal Sum (Other Acc.) PREMIUM $ 8.25
BAGGAGE AND PERSONAL EFFECTS $ none Amount of Insurance PREMIUM $ none
COMBINED PREMIUM $ ____ Term of Coverage: 5 Days
Countersigned by __________ Li[censed] __________
Name of [REDACTED b6/b7C] Address of Insured [REDACTED] City Gresham State Ore. Code [REDACTED] Name of Beneficiary ___ Address of Beneficiary [partially illegible] City ___ State ___ ZIP Code ___
Effective at: Hour 11:25 p.m. Date 11/23/71 Month Day Year Place PDX
Personal Signature of Insured [signature present]
AGENT COPY
---
DB Cooper-5439
(Copy for Agent)
Application No. T20T 084207 A
APPLICATION TO MUTUAL OF OMAHA INSURANCE COMPANY, OMAHA, NEBRASKA
Policy No. T20T
Name of Insured (Please Print): RANDOLPH. H.. BLAIN First Middle Last Date of Birth: 2-16-14
Principal Sum: $10,000
Medical Benefit: $ none (If the word "None" appears here, Part C "Medical Expense Benefits" is not in effect)
Address of Insured No. & Street: 720 [guess: NW] 5 [illegible] [guess: 25E], APT 48 City: CORVALLIS State: OR 973[guess: 30]
Occupation: Retired
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") 1. SCHEDULED AIRLINES............... Yes 2. AIRPORT PREMISES; AIRPORT BUS AND LIMOUSINE SERVICE.... Yes 3. COMMON CARRIER.................. [illegible mark] 4. AUTOMOBILE AND OTHER SPECIFIED AIRCRAFT.............. [illegible mark] 5. OTHER ACCIDENTS (NONOCCUPATIONAL).............. no
What amount of individual renewable travel accident insurance do you now have with Mutual of Omaha Insurance Company? Issued $ [illegible] Pending $ [illegible]
Name of Beneficiary: [illegible] Relationship: [illegible] Address of Beneficiary: No. & Street: [illegible] City: Ogden State: Utah
Insured's Signature: Randolph K. Blain
Countersigned by: [blank]
Agent's No.: [blank] Policy Date: 11-23-71 First Renewal Date: 12-1-72 Premium: Amount 10.00 Mode.... A
Form 485M App (Series 6490)
---
DB Cooper-5440
Policy Number A 32700 PERSONAL ACCIDENT AND SICKNESS Amount of Insurance $ 15,000 Insured Only Premium $ 8.65 Dependent Premium $ 3.50 TOTAL PREMIUM $ 12.15
BAGGAGE AND PERSONAL EFFECTS $ [illegible] Amount of Insurance PREMIUM $ [illegible]
COMBINED PREMIUM $______ Term of Coverage: 14 Days
Co[untersigned by] ______ Lic[ensed] ______
Name of Insured [REDACTED b6/b7C] Address of Insured [REDACTED b6/b7C] City Oregon City State Ore ZIP Code [blank] Name of Beneficiary [blank] Address of Beneficiary [blank] City Barksdale AFAB La. Code 71110 Effective at: NOON Hour 12:00 PM Date 11 - 24 - 71 Month Day Year Place PDX Personal Signature of Insured X [signature present] AGENT COPY
---
Policy Number A 059972 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $ 100,000 Capital Sum (Scheduled Air) $ 50,000 Principal Sum (Other Acc.) PREMIUM $ 7.50
BAGGAGE AND PERSONAL EFFECTS $ None Amount of Insurance PREMIUM $ none
COMBINED PREMIUM $______ Term of Coverage: 2 Days
Countersigned by ______
Name of Insured [REDACTED b6/b7C] [guess: Occupation] [REDACTED b6/b7C] Address of Insured [REDACTED b6/b7C] City Portland State Ore. ZIP Code [blank] Name of Beneficiary [REDACTED b6/b7C] Address of Beneficiary [blank] City Portland State Ore ZIP Code [blank] Effective at: Hour 6:50 PM Date 11 - 24 - 71 Month Day Year Place PDX Personal Signature of Insured [signature present] AGENT CO[PY]
---
DB Cooper-5441
---
b6 b7C
Policy Number A 058904
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $60,000 Capital Sum (Scheduled Air) $30,000 Principal Sum (Other Acc.) PREMIUM $ 5.00
BAGGAGE AND PERSONAL EFFECTS $ none Amount of Insurance PREMIUM $ none
COMBINED PREMIUM $______ Term of Coverage: 1 Days
Co[mpany - cut off] Li[ability - cut off]
--- Please Print --- Name of Insured [REDACTED b6/b7C] Occupation Address of Insured [REDACTED b6/b7C] City Portland State Ore ZIP Code Name of Beneficiary [REDACTED b6/b7C] Address of Beneficiary [REDACTED b6/b7C] City [guess: Salem] State [illegible] ZIP Code
Effective at: Hour 7:00 ☒ p.m. Date 11 - 24 - 71 Month Day Year Place PDX
Personal Signature of Insured [signature present but redacted]
AGENT COPY
---
Policy Number A 058906
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $60,000 Capital Sum (Scheduled Air) $30,000 Principal Sum (Other Acc.) PREMIUM $ 8.25
BAGGAGE AND PERSONAL EFFECTS $ /0ne Amount of Insurance PREMIUM $ /0ne
COMBINED PREMIUM $______ T[erm of Coverage - cut off] [illegible lines]
--- Please Print --- Name of Insured [REDACTED b6/b7C] Address of Insured [REDACTED b6/b7C] City Parkdale State Ore ZIP Code Name of Beneficiary [REDACTED b6/b7C] Address of Beneficiary [REDACTED b6/b7C] City [guess: Salem] State [line through] ZIP Code
Effective at: Hour 7:30 ☒ p.m. Date 11 - 24 - 71 Month Day Year Place PDX
Personal Signature of Insured [blank or redacted]
AGENT COPY
---
DB Cooper-5442
Policy Number A 059973 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $60,000 Capital Sum (Scheduled Air) $30,000 Principal Sum (Other Acc.) PREMIUM $5.25
BAGGAGE AND PERSONAL EFFECTS $ none Amount of Insurance PREMIUM $ none
COMBINED PREMIUM $________ Term of Coverage: _______ Days Countersigned by
--- Please Print --- Name of Insured: [REDACTED b6/b7C] Occupation: [REDACTED b6/b7C] Address of Insured: [REDACTED] City: La Grande State: Ore. ZIP Code: [REDACTED] Name of Beneficiary: [REDACTED] Address of Beneficiary: [guess: Same] [partially illegible handwriting] City: [blank] State: [blank] ZIP Code: [blank]
Effective at: Hour 7:30 p.m. ☒ Date 11-24-71 Place: PDX
Personal Signature of Insured: [REDACTED] AGENT: [blank]
---
Policy Number A 059974 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $60,000 Capital Sum (Scheduled Air) $30,000 Principal Sum (Other Acc.) PREMIUM $5.25
BAGGAGE AND PERSONAL EFFECTS $ none Amount of Insurance PREMIUM $ none
COMBINED PREMIUM $________ Term of Coverage: 3 Days Countersigned by
--- Please Print --- Name of Insured: [REDACTED b6/b7C] Occupation: [REDACTED b6/b7C] Address of Insured: [REDACTED] City: Portland State: Ore. ZIP Code: [REDACTED] Name of Beneficiary: [REDACTED] Address of Beneficiary: [guess: Same] City: [blank] State: [blank] ZIP Code: [blank]
Effective at: Hour 7:40 p.m. ☒ Date 11-24-71 Place: PDX
Personal Signature of Insured: [REDACTED] AGENT: [blank]
---
DB Cooper-5443
Policy Number A 33266 PERSONAL ACCIDENT AND SICKNESS $ 20,000 Amount of Insurance Insured Only Premium $ 5.25 Dependent Premium $ 1.60 TOTAL PREMIUM $ 6.85
BAGGAGE AND PERSONAL EFFECTS $ none Amount of Insurance PREMIUM $ none
COMBINED PREMIUM $ ______ Term of Coverage: 5 Days
Countersigned by ____________________________
--- Please Print --- Name of Insured [REDACTED b6/b7C] Occupation [REDACTED] Address of Insured [REDACTED] City Portland State Ore. ZIP Code [blank] Name of Beneficiary Estate of insured Address of Beneficiary [partially legible] ZIP Code [blank] City [illegible] State [illegible]
Effective at: Hour 7:45 [X] a.m. [ ] p.m. Date 11-24-71 Month Day Year Place PDX Personal Signature of Insured [REDACTED] AGE [REDACTED]
---
Policy Number A 059976 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $ 20,000 Capital Sum (Scheduled Air) $ 16,000 Principal Sum (Other Acc.) PREMIUM $ 4.75
BAGGAGE AND PERSONAL EFFECTS $ 3,000 Amount of Insurance PREMIUM $ 3.75
COMBINED PREMIUM $ 8.50 Term of Coverage: 10 Days
Countersigned by ____________________________ Licensed Resident Agent
--- Please Print --- Name of Insured [REDACTED b6/b7C] Occupation [REDACTED] Address of Insured [REDACTED] City Salem State Ore. Code [blank] Name of Beneficiary [blank] Address of Beneficiary [blank] City [guess: Same] ZIP Code [blank]
Effective at: Hour 9:00 [X] a.m. [ ] p.m. Date 11-24-71 Month Day Year Place PDX Personal Signature of Insured [REDACTED] AGENT CO[cut off]
---
DB Cooper-5444
Please Print Policy Number A 058907
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $80,000 Capital Sum (Scheduled Air) $40,000 Principal Sum (Other Acc.) PREMIUM $4.00
BAGGAGE AND PERSONAL EFFECTS $[guess: 2,000] Amount of Insurance PREMIUM $[illegible]
COMBINED PREMIUM $________ Term of Coverage: _______ Days
Count[y] Licens[e]
Name of Insured [REDACTED] Address of Insured [REDACTED] City [guess: Portland] State Ore ZIP Code [illegible] Name of Beneficiary [REDACTED] Address of Beneficiary [REDACTED] City [illegible] State [illegible] ZIP Code [illegible]
Effective at: Hour 8:15 [☒]a.m. [☐]p.m. Date 11 - 24 - 71 Month Day Year Place PDX
Personal Signature of Insured __________
AGENT COP[Y]
---
Please Print Policy Number A 058910
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $20,000 Capital Sum (Scheduled Air) $10,000 Principal Sum (Other Acc.) PREMIUM $2.25
BAGGAGE AND PERSONAL EFFECTS $300 Amount of Insurance PREMIUM $3.75
COMBINED PREMIUM $[guess: 8.50] Term of Coverage: 10 Days
Name of Insured [REDACTED] Address of Insured [REDACTED] City [guess: Tigard] State Ore Code [blank] Name of Beneficiary [REDACTED] Address of Beneficiary [REDACTED] City San Diego State Calif ZIP Code [blank]
Effective at: Hour 8:40 [☒]a.m. [☐]p.m. Date 11 - 24 - 71 Month Day Year Place PDX
Personal Signature of Insured __________
AGENT CO[PY]
---
b6 b7C
---
DB Cooper-5445
Policy Number A 058911
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $60,000 Capital Sum (Scheduled Air) $20,000 Principal Sum (Other Acc.) PREMIUM $ 8.25
BAGGAGE AND PERSONAL EFFECTS $ [guess: 10M] Amount of Insurance PREMIUM $ [partially illegible]
COMBINED PREMIUM $ ______ Term of Coverage: ______ Days
Co[untersigned by] _______________ Li[censed Resident Agent] _______________
--- Please Print --- Name of [REDACTED b6, b7C] Address of Insured [REDACTED b6, b7C] City Portland State Ore ZIP Code ___ Name of Beneficiary [REDACTED b6, b7C] Address of Beneficiary [REDACTED b6, b7C] City [guess: Same] State ___ ZIP Code ___ Effective at: Hour 8:45 PM Date 11 - 24 - 71 Month Day Year Place PDX Personal S[tatement] of Insured ___ AGE[NT] ___
---
Policy Number A 33267
PERSONAL ACCIDENT AND SICKNESS $ 25,000 Amount of Insurance Insured Only Premium $ 8.15 Dependent Premium $ 2.15 TOTAL PREMIUM $ 10.30
BAGGAGE AND PERSONAL EFFECTS $ NONE Amount of Insurance PREMIUM $ NONE
COMBINED PREMIUM $ ______ Term of Coverage: 7 Days
Countersigned by _______________ Licensed Resident Agent _______________
--- Please Print --- Name of [REDACTED b6, b7C] Occupation [REDACTED b6, b7C] Address of Insured [REDACTED b6, b7C] City Vancouver State Wash ZIP Code ___ Name of Beneficiary [REDACTED b6, b7C] Address of Beneficiary [guess: Same] City ___ State ___ ZIP Code ___ Effective at: Hour 9:00 PM Date 11 - 24 - 71 Month Day Year Place PDX Personal S[tatement] of Insured ___ AGE ___
DB Cooper-5446
Serials: 084207, A 058887, A 058888, A 058895, A 058897, A 058898, A 058899, A 058900