| Agent | Libertas General Insurance Head Office |
|---|
| Agent Code | BT001 |
|---|
| Effective Date | 10/10/2017 |
|---|
| Expiry Date | 01/07/2018 |
|---|
| Plan | Plan A (World Wide Excluding USA & Canada) |
|---|
| Cover | Full Package A-I |
|---|
| Name of Policy Holder | Domnick Romeu Gomes |
|---|
| Policy Number | T/BT269 |
|---|
| Country of Origin | Malawi |
|---|
| Destination Area | United Kingdom |
|---|
| Address | P.O Box 5082,
Limbe.
|
|---|
| Number of Passengers | 1 |
|---|
| List of persons insured | | Name |
Passport Number |
Age |
Premium |
|---|
| Domnick Romeu Gomes |
706454226 |
67 |
159,344.20 |
|
|---|
| Net Premium (Before Tax) | 159,344.79 |
|---|
| Total Premium (After Tax) | 186,635.99 |
|---|
| Signed by |  |
|---|
