Part 18, page 106

Transcript

The scan is the source; the transcript is machine-generated from it.

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

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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

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DB Cooper-5439