Agent | Libertas | ||||||||
---|---|---|---|---|---|---|---|---|---|
Agent Code | 001 | ||||||||
Effective Date | 02/02/2014 | ||||||||
Expiry Date | 03/01/2014 | ||||||||
Plan | Plan A (World Wide Excluding USA & Canada) | ||||||||
Cover | Medical Only A-C | ||||||||
Name of Policy Holder | Marshall Dyton | ||||||||
Policy Number | T001 | ||||||||
Country of Origin | Malawi | ||||||||
Destination Area | Canada | ||||||||
Address | XYZ123 | ||||||||
Number of Passengers | 1 | ||||||||
List of persons insured |
| ||||||||
Net Premium (Before Tax) | 2000 | ||||||||
Total Premium (After Tax) | 2000 | ||||||||
Signed by |