| Agent | Libertas General Insurance Head Office |
|---|
| Agent Code | BT001 |
|---|
| Effective Date | 01/20/2019 |
|---|
| Expiry Date | 01/25/2019 |
|---|
| Plan | Plan A (World Wide Excluding USA & Canada) |
|---|
| Cover | Full Package A-I |
|---|
| Name of Policy Holder | Victor Chagunyuka Mhango |
|---|
| Policy Number | T/BT401 |
|---|
| Country of Origin | Malawi |
|---|
| Destination Area | Tbilisi-Georgia |
|---|
| Address | P.O Box 30250
Blantyre 3
|
|---|
| Number of Passengers | 1 |
|---|
| List of persons insured | | Name |
Passport Number |
Age |
Premium |
|---|
| Victor Chagunyuka Mhango |
MA890405 |
44 |
43,674.80 |
|
|---|
| Net Premium (Before Tax) | 43,674.80 |
|---|
| Total Premium (After Tax) | 51,881.14 |
|---|
| Signed by |  |
|---|
