| Agent | Libertas General Insurance Head Office |
|---|
| Agent Code | TBA |
|---|
| Effective Date | 12/18/2017 |
|---|
| Expiry Date | 01/18/2018 |
|---|
| Plan | Plan B (World Wide Including USA & Canada) |
|---|
| Cover | Medical Only A-C |
|---|
| Name of Policy Holder | Dennis Stravrols Yiannakis |
|---|
| Policy Number | T/KF166 |
|---|
| Country of Origin | Malawi |
|---|
| Destination Area | USA |
|---|
| Address | Private Bag 154
Blantyre
|
|---|
| Number of Passengers | 1 |
|---|
| List of persons insured | | Name |
Passport Number |
Age |
Premium |
|---|
| Dennis Stravrols Yiannakis |
MA593675 |
9 |
83,908.60 |
|
|---|
| Net Premium (Before Tax) | 83,908.60 |
|---|
| Service Fees | 0.00 |
|---|
| Total Premium (After Tax) | 97,763.52 |
|---|
| Signed by |  |
|---|
