Mutual of Omaha travel accident insurance application No. T20T 084005 A (agent copy)
Document date 24 November 1971
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Id: Cooper-Part-18:118-118
Subject: Cooper Files: Cooper-Part-18:118-118 Document: Mutual of Omaha travel accident insurance application No. T20T 084005 A (agent copy) Id: Cooper-Part-18:118-118 Page: https://cooper.theunsolved.net/documents/Cooper-Part-18%3A118-118 What is wrong (title, date, type, which pages belong together, copies)? What does the scan show?
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FBI 164-81, Vault Part 18 p. 118 (DB Cooper-5451), Form, dated 24 Nov 1971 — cooper.theunsolved.net/documents/Cooper-Part-18%3A118-118
(Copy for Agent)
Application No. T20T 084005 A
APPLICATION TO MUTUAL OF OMAHA INSURANCE COMPANY, OMAHA, NEBRASKA
Policy No. T20T
Name of Insured (Please Print): [redacted] Date of Birth: [redacted] First Middle Last
Principal Sum Medical Benefit $ 100900 NONE (If the word "None" appears here, Part C "Medical Expense Ben- efits" is not in effect)
Address of Insured: No. & Street: [redacted] City: Portland, State: Ore.
Occupation: [blank]
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.................. No 4. AUTOMOBILE AND OTHER SPECIFIED AIRCRAFT.............. No 5. OTHER ACCIDENTS (NONOCCUPATIONAL)............... No
What amount of individual renewable travel accident insurance do you now have with Mutual of Omaha Insurance Company? Issued $...None........... Pending $...None...........
Name of Beneficiary: [redacted] Relationship: [blank]
Address of Beneficiary: No. & Street: [redacted] City: Portland, State: Ore.
Insured Signature: [blank]
Co[mpany]: [blank] Agent's No.: [blank] Policy Date: 11-24-71 First Renewal Date: 12-1-72 Premium: Amount...........$40.00 Mode..............A Li[cense]: [blank]
Form 485M App (Series 6490)
DB Cooper-5451
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b6 b7C
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DB Cooper-5451
Serials: 084005