◆ SpookStack

fe S26 he +. b6 b7C Policy ame of Insured Ramer A 32700 [moet PERSONAL ACCIDENT AND SICKNESS sLS, ODOC) amount of Insurance of Insured Insured Only Premium §$ City Ore Co» . | Name of Benefici Dependent Premium $ TOTAL PREMIUM $ 4 BAG E AND PERSONAL EFFECTS | Address of Beneficia tO $ Amount of JdStrance ~ . i PREMIUM aty ’ . , . Effective at: A/OD/~ pac__“- AV -Y a.m. Hour 42:90 “TF p.m. . Month Day Year My so bl ar beded ier kl ee + . COMBINED PREMIUM $ Term of Coverage: Personal Signature - of Insured Policy : ; ) MS , . Number { oo7. a Ps PERSONAL ACCIDENT WITH [aqarew cesta SCHED mount of \asurance 7 u : . s{QS.OCD Capital Sum (Scheduled Air) | city “Poy, nd State OveE- Code $ Principal Sum (Other Acc.) = : PREMIUM $2.20 | Name of Benois ee ee ee BAGGAGE AND PERSONAL EFFECTS | Address of Benefidary] sSACKAS— _ Amount of Insurance. - | - ; . ZIP AT Bee PREMIUM § HL | city <P f& (curd state OUR Code a “4 Effective at: ( , y am ° COMBINED PREMIUM $ Hour ©. 50 i nt Date LL -aee ‘ Term of Coverage: . , Month Day = Year ‘Veress eeusee