The United States of America
Treasury Department
Beaureau of War Risk Insurance
Washington, D.C.

This Certifies That ___________________________ has applied for insurance in the amount of $10,000, payable in case of death or total permanent disability in monthly installments of $57.50
Subject to the payment of the premiums required, this insurance is granted under the authority of an Act amending "An Act entitled 'An Act to authorize the establishment of a Bureau of War Risk Insurance in the Treasury Department,' approved September 2, 1914, and for other purposes," approved October 6, 1917, and subject in all respects to the provisions of such Act, of any amendments thereto, and of all regulations thereunder, now in force or hereafter adopted, all of which, together with the application for this insurance, and the terms and conditions published under authority of the Act, shall constitute the contract.

Secretary of the Treasury
Countersigned at Washington, D.C.

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