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RELSAES

AUTOMOBILE INSURANCE CERTIFICATE
Issued by

PHGENIX INDEMNITY COMPANY

To
Forrest C. Allen
of wawrence, Kansas who is insured under

Policy No.4 214235 Expiring 3/15/41

(unless cancelled prior thereto)
—————~ <2 __
TO ANY REPRESENTATIVE OF THE COMPANY:

On presentation of this Certificate, you are requested to render our Assured the
services specified on the reverse hereof and to extend every courtesy reasonably within
your power. In case of an accident covered by our. policy, or should a release of
attachment bond be required, you are authorized to telegraph the Company, collect,
for verification of coverage, and instructions,

Policy Issued by Charlton Ins. Agcy.
wrence, Ks.

 

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EMERGENCY. ACCIDENT REPORT
The Accident A. M.

Date Hour

EMERGENCY AGGIDENT ‘REPORT

The - A.M.

Date Hour

 

Place where Accident occurred (St. or Rd.)

 

Place where Accident occurred (St. or Rd.)

 

 

 

 

City State City State
Your Car Your Car
Engine No. Mfrs. Serial No. Engine No. Mfrs. Serial No.
Make of Car Age of Driver Make of Car Age of Driver

 

 

 

Name of Owner

 

Name of Owner

 

Name of Driver

Name of Driver

 

 

 

 

The Other Car The Other Car
Name of Owner Name of Owner
Address of Owner Address of Owner
Description of Accident Description of Accident

 

 

SEBLEEAEEELEEEEEEEEE ELE LEELA

 

 

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