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2% s* ae - _ 2 ae . “ws et woo. .* ee eee ee Tae ote Kaw Nidal) ee ae a tay ee a ee ne ' te ice so . Application No. T200T O84207 a APPLICATION TO MUTUAL OF OMAHA INSURANCE goMPany, OMAHA, NEBRASKA Son re Ne aaah. th. . AAG dee wens Bath, anlar debe ae ress of No, LOMW SSC, THES City COR YA AAL State SP? S734 Occupation Ke tiepe of What amount of individual renewable travel accident insurance do you now have with Mutual of Omaha Insurance Company? Issued_$ SAYS Pending $ AY Name o elation: Medical Benefit (if the word noe appears here, Part C “Medical Expense Ben- efits” is not in effect) Coverages (Insurance is provided under this policy only with respect to those coverages shown below which are followed b rape word “Yes” rather than by the word “ 1. SCHEDULED AIRLINES. wneeeneee Yes 2. AIRPORT PREMISES; AIRPORT BUS AND LIMOUSINE SERVICE. ... Yes 3. COMMON CARRIER, ........22055.%4 4, AUTOMOBILE AND OTHER SPECIFIED AIRORAFT........ bas . OTHER ACCIDENTS Og Amount 10105. Mode. ...Asssess Form 485M App orton 6490) 2 - - ~ ~ . _ an Aa, a - ~ = - > : e 2 ‘. 740 woe » sf ~ * _ at . _ iad Y = BE ate e YDB Cooper- 5440 ey i a See i) . » " : . ae, ° T -