Part 18, page 138

Transcript

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

MUTU DUPLICATE APPLICATION Premium Paid WRITE Resident Agent Point of Departure .. Portland .......... [illegible] Trip to be made on: Destination: Jamestown N. Dakota ☐ One-way Ticket Time ☐ Round-

Insured's Name .. Beneficiary's Name ..

Street -

City: ..1..1..9. [guess: PRO].... State ..ORE...... Insured is owner unless checked here: ☐ Beneficiary is owner.

Insured's *Signature ................................ 842M App -M - Series 30165

► APPLICATION RETAINED BY MACHINE ◄

The Principal Sum of this policy is that amount which the premium stamped on the above application will purchase in accordance with the Rate Schedule on the reverse side. The policy requires advance ticketing for designated round trip (except shuttle or in-flight ticketing) before leaving Point of Departure as specified in Part A. The Maximum Principal Sum for which this policy may be issued is $75,000. In the event that the premium stamped on the application is greater than the applicable premium specified in the Rate Schedule for said maxi- mum Principal Sum, the excess premium will be re- turned upon demand. This insurance is binding only if the application has been completed and personally signed by the Insured and has been stamped by the Tele-Trip validator machine.

SCHEDULED AIRLINE TRIP INSURANCE POLICY

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[IMPORTANT] THIS CARD IS TO BE ENCLOSED IN SLOT DEPOSIT 25¢ ON POLICY MACHINE

[Form fields, partially legible:] [illegible] .......... State ......... Departure ................. [illegible] 1½ to 62 ☐ One-way ☐ Round [guess: Made] on: Ticket trip Ticket Date and Time of Purchase .. Insured is owner ☐ Beneficiary unless checked here: is owner. Signature of Insured .. [illegible] 844M App

T33AV-M2 [handwritten:] 2mrs [or similar]

[Below, inverted/mirrored text visible:] [guess: 11/61 '72 -1201[illegible]] [handwritten entries, partially illegible] [guess: ticket] ☐ [guess: Bond] ☐ [guess: Money] [illegible] [illegible handwritten amounts and signatures]

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DESIGNATED NO POLICY MACHINE DEPOSITED IN SLOT THIS CARD IS TO BE

IMPORTANT

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DB Cooper-5471