Part 18, page 112
FBI 164-81, Vault Part 18 p. 112 (DB Cooper-5445), Form — cooper.theunsolved.net/parts/Cooper-Part-18/pages/112
Transcript
The scan is the source; the transcript is machine-generated from it.
Please Print Policy Number A 058907
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $80,000 Capital Sum (Scheduled Air) $40,000 Principal Sum (Other Acc.) PREMIUM $4.00
BAGGAGE AND PERSONAL EFFECTS $[guess: 2,000] Amount of Insurance PREMIUM $[illegible]
COMBINED PREMIUM $________ Term of Coverage: _______ Days
Count[y] Licens[e]
Name of Insured [REDACTED] Address of Insured [REDACTED] City [guess: Portland] State Ore ZIP Code [illegible] Name of Beneficiary [REDACTED] Address of Beneficiary [REDACTED] City [illegible] State [illegible] ZIP Code [illegible]
Effective at: Hour 8:15 [☒]a.m. [☐]p.m. Date 11 - 24 - 71 Month Day Year Place PDX
Personal Signature of Insured __________
AGENT COP[Y]
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Please Print Policy Number A 058910
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $20,000 Capital Sum (Scheduled Air) $10,000 Principal Sum (Other Acc.) PREMIUM $2.25
BAGGAGE AND PERSONAL EFFECTS $300 Amount of Insurance PREMIUM $3.75
COMBINED PREMIUM $[guess: 8.50] Term of Coverage: 10 Days
Name of Insured [REDACTED] Address of Insured [REDACTED] City [guess: Tigard] State Ore Code [blank] Name of Beneficiary [REDACTED] Address of Beneficiary [REDACTED] City San Diego State Calif ZIP Code [blank]
Effective at: Hour 8:40 [☒]a.m. [☐]p.m. Date 11 - 24 - 71 Month Day Year Place PDX
Personal Signature of Insured __________
AGENT CO[PY]
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b6 b7C
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DB Cooper-5445