| Agent | Guardian Insurance |
|---|
| Agent Code | 3004 |
|---|
| Effective Date | 10/07/2018 |
|---|
| Expiry Date | 11/11/2018 |
|---|
| Plan | Plan A (World Wide Excluding USA & Canada) |
|---|
| Cover | Medical Only A-C |
|---|
| Name of Policy Holder | Stella Chimwemwe Mlewa |
|---|
| Policy Number | T/GISLL457 |
|---|
| Country of Origin | Malawi |
|---|
| Destination Area | Mamhattan - Kansas State - USA |
|---|
| Address | P.O. Box 404
Lilongwe
|
|---|
| Number of Passengers | 1 |
|---|
| List of persons insured | | Name |
Passport Number |
Age |
Premium |
|---|
| Stella Chimwemwe Mlewa |
MA146570 |
30 |
83,908.60 |
|
|---|
| Net Premium (Before Tax) | 83,908.60 |
|---|
| Total Premium (After Tax) | 98,753.52 |
|---|
| Signed by |  |
|---|
