Part 18, page 114

Transcript

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

Policy Number A 059979 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: 4 Days Countersigned by :

Licensed Resident Agent

--- Please Print --- N[REDACTED] [REDACTED]cupation Address of Insured [REDACTED] City Portland State Ore. ZIP Code Name of Beneficia[ry] [REDACTED] Address of Beneficiary City State Same ZIP Code

Effective at: Hour 9:00 [checked] p.m. Date 11-24-71 Month Day Year Place PDX

Personal Signature of Insured [REDACTED]

AGENT CO[PY]

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Policy Number A 059981 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: 4 Days Countersigned by :

--- Please Print --- [REDACTED] Address of Insured [REDACTED] City Monmouth State OR. ZIP Code Name of Beneficia[ry] [REDACTED] Address of Beneficiary City State Same ZIP Code

Effective at: Hour 10:30 [checked] p.m. Date 11-24-71 Month Day Year Place PDX

Personal Signature of Insured [REDACTED]

AGENT COPY

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b6 b7C

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DB Cooper-5447