Part 18, page 118

Transcript

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

(Copy for Agent)

Application No. T20T 084005 A

APPLICATION TO MUTUAL OF OMAHA INSURANCE COMPANY, OMAHA, NEBRASKA

Policy No. T20T

Name of Insured (Please Print): [redacted] Date of Birth: [redacted] First Middle Last

Principal Sum Medical Benefit $ 100900 NONE (If the word "None" appears here, Part C "Medical Expense Ben- efits" is not in effect)

Address of Insured: No. & Street: [redacted] City: Portland, State: Ore.

Occupation: [blank]

Coverages (Insurance is provided under this policy only with respect to those coverages shown below which are followed by the word "Yes" rather than by the word "No") 1. SCHEDULED AIRLINES.............. Yes 2. AIRPORT PREMISES; AIRPORT BUS AND LIMOUSINE SERVICE....... Yes 3. COMMON CARRIER.................. No 4. AUTOMOBILE AND OTHER SPECIFIED AIRCRAFT.............. No 5. OTHER ACCIDENTS (NONOCCUPATIONAL)............... No

What amount of individual renewable travel accident insurance do you now have with Mutual of Omaha Insurance Company? Issued $...None........... Pending $...None...........

Name of Beneficiary: [redacted] Relationship: [blank]

Address of Beneficiary: No. & Street: [redacted] City: Portland, State: Ore.

Insured Signature: [blank]

Co[mpany]: [blank] Agent's No.: [blank] Policy Date: 11-24-71 First Renewal Date: 12-1-72 Premium: Amount...........$40.00 Mode..............A Li[cense]: [blank]

Form 485M App (Series 6490)

DB Cooper-5451

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b6 b7C

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DB Cooper-5451