| Agent | Libertas General Insurance Head Office |
|---|
| Agent Code | BT001 |
|---|
| Effective Date | 12/15/2018 |
|---|
| Expiry Date | 12/29/2018 |
|---|
| Plan | Plan A (World Wide Excluding USA & Canada) |
|---|
| Cover | Full Package A-I |
|---|
| Name of Policy Holder | Tom Mtenje |
|---|
| Policy Number | T/STD/005/BT |
|---|
| Country of Origin | Malawi |
|---|
| Destination Area | Zimbabwe,South Africa |
|---|
| Address | P.O Box 31724
Lilongwe.
|
|---|
| Number of Passengers | 1 |
|---|
| List of persons insured | | Name |
Passport Number |
Age |
Premium |
|---|
| Tom Mtenje |
MA56389 |
39 |
41,314.20 |
|
|---|
| Net Premium (Before Tax) | 41,314.20 |
|---|
| Total Premium (After Tax) | 49,131.04 |
|---|
| Signed by |  |
|---|
