| Agent | Libertas General Insurance Head Office |
|---|
| Agent Code | BT001 |
|---|
| Effective Date | 12/08/2017 |
|---|
| Expiry Date | 02/07/2018 |
|---|
| Plan | Plan A (World Wide Excluding USA & Canada) |
|---|
| Cover | Medical Only A-C |
|---|
| Name of Policy Holder | Mervis Liwasha |
|---|
| Policy Number | T/BT286 |
|---|
| Country of Origin | Malawi |
|---|
| Destination Area | Denmark |
|---|
| Address | P. O. Box 1022
Blantyre
|
|---|
| Number of Passengers | 1 |
|---|
| List of persons insured | | Name |
Passport Number |
Age |
Premium |
|---|
| Mervis Liwasha |
MA951485 |
33 |
72,002.00 |
|
|---|
| Net Premium (Before Tax) | 72,002.00 |
|---|
| Service Fees | 0.00 |
|---|
| Total Premium (After Tax) | 83,882.33 |
|---|
| Signed by |  |
|---|
