Part 18, page 104
FBI 164-81, Vault Part 18 p. 104 (DB Cooper-5437), Form — cooper.theunsolved.net/parts/Cooper-Part-18/pages/104
Transcript
The scan is the source; the transcript is machine-generated from it.
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
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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
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b6 b7C
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DB Cooper-5437