National Standard

Automobile Liability Policy
FORM 4304

DECLARATIONS

- moans

Item 1. Name of insured

The named insnred_ ie

No, A 214235

A Capital Stock Company

 

ee ema
— ae

Forrest C. Allen

Individual

(ndividual, corporation, or co-partnership—if latter, give names of partriere)

)1 Louisiana Street... Lawrence Douglas. Kansas
Street Town County State} “
ncipally garaged and used in the above town, county and state, unless otherwise specified

Lawrence, Kansas

ied insured is._Athletiec Instr. & Coach - Kansas University

(if married woman, give husband’s occupation or business)

Loewen ie gk eee Xe Mareh.15 19_AL.

ne at the address of the named insured as stated herein.

only with respect to such and so many of the following coverages as are indicated
charge or charges. The limit of the company’s liability against each such coverage
subject to all of the terms of the policy having reference thereto.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Limits of Liability Automobile awe Na. 2
$10,000.00 each person
¢ 20,000.00 each accident + 13.80 ,
$ 5,000.00 each accident |$ 4,80 $
Hil.
Nil. i
“ae Total Premium | $18.60 $
Type of Body Serial No. No. of Cylinders
} (Load Capacity, if Truck and sal
Gallon Cap., if Tank Body) Motor No. Medel
Sedan S 13262143 oe
m 83402753 ma, 98-81
s Cyls.
M Mal.

 

 

 

 

és for which the automobile is to be used are... rleasure and business ss

 

fhe term “pleasure and business” is defined as personal, pleasure, family and business use. (6b) The term “commer-

ad” is defined as use principally in the business occupation of the named insured as stated in ltem 1, including occasional

use for personal, pleasure, family and ether business purposes. (c) Use of the automobile for the purposes stated includes
the loading and unloading thereof.

mn 6. The named insured is the sole owner of the automobile, except as herein stated:

 

No exceptions

Item 7. No insurer has canceled any automobile insurance issued to the named insured, nor declined to issue such

insurance, during the past year, except as herein stated: No..exceptions

 

Date and place of issue__. Mareh.15,..1940. 0 TheAY

Lawrence, Kansas

   

Countersigned by utk-€Cé2EZR. Cf. Med ee Be
Authorized Representative: