Part 18, page 107

Transcript

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

(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)

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DB Cooper-5440