Part 18, page 116
Document date 24 November 1971
FBI 164-81, Vault Part 18 p. 116 (DB Cooper-5449), Form, dated 24 Nov 1971 — cooper.theunsolved.net/parts/Cooper-Part-18/pages/116
Transcript
The scan is the source; the transcript is machine-generated from it.
Policy Number A 058912
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $ 40,000 Capital Sum (Scheduled Air) $ 25,000 Principal Sum (Other Acc.) PREMIUM $ 9.50
BAGGAGE AND PERSONAL EFFECTS $ [guess: 500] Amount of Insurance PREMIUM $ [illegible]
COMBINED PREMIUM $______ Term of Coverage: 10 Days
Counte[r] _______________
Licens[e] _______________
--- Right side ---
Please Print Name of Insured [redacted] Address of Insured [redacted] City Tillamoo[k] State Ore ZIP Code ___ Name of Beneficiary _______________ Address of Beneficiary _______________ City Bothell State Wash ZIP Code ___ Effective at: Hour 11:30 [X] a.m. Date 11 - 24 - 71 Month Day Year Place PDX Personal Signature of Insured X [signature present]
AGENT COPY
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Policy Number A 058916
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $ 20,000 Capital Sum (Scheduled Air) $ 10,000 Principal Sum (Other Acc.) PREMIUM $ [guess: 5.00]
BAGGAGE AND PERSONAL EFFECTS $ [guess: 1,000] Amount of Insurance PREMIUM $ [illegible]
COMBINED PREMIUM $______ Term of Coverage: 14 Days
Cou[nter] _______________
Lic[ense] _______________
--- Right side ---
Please Print Name of Insured [redacted] Address of Insured [redacted] City Kalama State Wash ZIP Code ___ Name of Beneficiary _______________ Address of Beneficiary _______________ City Kalama State Wash ZIP Code ___ Effective at: Hour 1:00 [X] p.m. Date 11 - 24 - 71 Month Day Year Place PDX Personal Signature of Insured [signature present]
AGENT COPY
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b6 b7C
DB Cooper-5449