| Agent | Libertas Lilongwe |
|---|
| Agent Code | LL001 |
|---|
| Effective Date | 03/05/2018 |
|---|
| Expiry Date | 03/09/2018 |
|---|
| Plan | Plan A (World Wide Excluding USA & Canada) |
|---|
| Cover | Full Package A-I |
|---|
| Name of Policy Holder | Dr. Jerome John Chim'gonda-Nkhoma |
|---|
| Policy Number | T/LL380 |
|---|
| Country of Origin | Malawi |
|---|
| Destination Area | Belgium |
|---|
| Address | P.O. Box 594,
Lilongwe
|
|---|
| Number of Passengers | 1 |
|---|
| List of persons insured | | Name |
Passport Number |
Age |
Premium |
|---|
| Dr. Jerome John Chim'gonda-Nkhoma |
MS000250 |
49 |
43,674.80 |
|
|---|
| Net Premium (Before Tax) | 51,881.14 |
|---|
| Service Fees | 0 |
|---|
| Total Premium (After Tax) | 51,881.14 |
|---|
| Signed by |  |
|---|
