Part 18, page 99

Transcript

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

Policy Number A 058901 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $20,000 Capital Sum (Scheduled Air) $10,000 Principal Sum (Other Acc.) PREMIUM $ 4.25

BAGGAGE AND PERSONAL EFFECTS $[illegible] Amount of Insurance PREMIUM $[illegible]

COMBINED PREMIUM $________ Term of Coverage: 10 Days

Co[illegible] Li[illegible]

--- Right side --- Please Print Name of Insured [redacted] Address of Insured [redacted] City Lake Oswego State Ore ZIP Code [blank] Name of Beneficiary [redacted] Address of Beneficiary [redacted] City [redacted] State [redacted] Code [redacted] Effective at: Noon Hour 12:05 p.m. Date 11 - 23 - 71 Month Day Year Place [illegible] Personal Signature of Insured X AGENT COPY

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Policy Number A 058899 PERSONAL ACCIDENT WITH DOUBLE PROTECTION ON SCHEDULED AIRLINES Amount of Insurance: $20,000 Capital Sum (Scheduled Air) $10,000 Principal Sum (Other Acc.) PREMIUM $ 4.25

BAGGAGE AND PERSONAL EFFECTS Amount of Insurance [illegible] PREMIUM $ [illegible]

COMBINED PREMIUM $________ Term of Coverage: 10 Days

Co[illegible] Li[illegible]

--- Right side --- Please Print Name of Insured [redacted] Address of Insured [redacted] City Portland State Ore ZIP Code [blank] Name of Beneficiary [redacted] Address of Beneficiary [redacted] City [redacted] State [redacted] Code [redacted] Effective at: Hour 8:25 p.m. Date 11 - 23 - 71 Month Day Year Place PDX Personal Signature of Insured [blank] AGENT COPY

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b6 b7C

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DB Cooper-5432