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mr. 3 Number A 059973 b7C Lt PERSONAL ACCIDENT WITH 4 : wie? DOUBLE PROTECTION ON . ; SCHEDULED AIRLINES Amount of Insurance: ©_ Capital Sum Scheduled Air) Priticipal Sum © ther Qe) :) PREMIUM $ BAGGAGE AND PERSONAL EFFECTS $_AAWKR. Amount of Insurance: - PREMIUM $form 1 So ee meter tte ee tone F Effective at: M . a.m. . ~— COMBINED PREMIUM $—___} 4,53 BO 7: pm. Date—lirQA ~—7/ Term of Coverage: | Month .. Day Year: < ey le le tert nahi ett genie. « Sete sn. ¥ a ' ! 4 aot ‘ Hogs >a ate . . ' - “¢ . i 4 * tp I i in in Occupation = ow PERSONAL ACCIDENT WITH ’ Address woth ty ee DOUBLE PROTECTION ON . AND Ao AIRLINES Princi um ie 0 Ohare) AE PASSE |e oe _—— Amount of Insurance: BAGGAGE AND PERSONAL EFFECTS | Address of LBenchicary - $ AA K2—— Amount of Insurance Ake) City Gute ~ Py ae Effective at: ” Hour 7/4082" Dm. pue__ Litas « Month Day Year Le 4s COMBINED PREMIUM $— Term of Coverage: _.____ Days Countersigned by . aoa. 8 . . . . ' . te 1 ‘ = . : “os SN RE EOE SAIS SSN Tp Say gg EIR EMT IIY FAEERTR RAE BER wet Ar PTO Ste NMG TS Rha vw eH Hy ‘ » DB"