Part 18, page 109

Transcript

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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

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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

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DB Cooper-5442