Part 18, page 117
Document date 24 November 1971
FBI 164-81, Vault Part 18 p. 117 (DB Cooper-5450), Form, dated 24 Nov 1971 — cooper.theunsolved.net/parts/Cooper-Part-18/pages/117
Transcript
The scan is the source; the transcript is machine-generated from it.
Policy Number A 059984
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 --- Name of [REDACTED b6/b7C] Occupation [REDACTED b6/b7C] Address of Insured [REDACTED b6/b7C] City Portland State Ore ZIP Code [REDACTED] Name of Beneficiary [REDACTED b6/b7C] Address of Beneficiary [REDACTED b6/b7C] City Fullerton State Calif. Code [REDACTED] Effective at: Hour 1:00 [X] p.m. Date 11-24-71 Place PDX Personal Signature of Insured [REDACTED]
AGENT COPY
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Policy Number A 059986
PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $60,000 Capital Sum (Scheduled Air) $30,000 Principal Sum (Other Acc.) PREMIUM $ 9.75
BAGGAGE AND PERSONAL EFFECTS $ None Amount of Insurance PREMIUM $ None
- COMBINED PREMIUM $________ Term of Coverage: 6 Days Countersigned by ________
--- Please Print --- Name of [REDACTED b6/b7C] Occupation [REDACTED b6/b7C] Address of Insured [REDACTED b6/b7C] City Portland State Or. ZIP Code [guess: 927] Name of Beneficiary [REDACTED b6/b7C] Address of Beneficiary [guess: Same] City [REDACTED] State [REDACTED] ZIP Code [REDACTED] Effective at: Hour 2:15 [X] p.m. Date 11-24-71 Place PDX Personal Signature of Insured [REDACTED]
AGENT COPY
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DB Cooper-5450
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b6 b7C