12. (See haus-bons on reverse). AMOUNT OF CLAN On dollars) 12e. PROPERTY DAMAGE 12b. PERSONAL INJURY 20,000,000 IN. WRONGFUL DEATH 12d. TOTAL (FaOuro to spec* may cause lode) ma of you Gas). 20,000,000 I CERTFY THAT THE AMOUNT OF CLAIM COVERS ONLY DAMAGES AND INJURES CAUSED BY THE INCIDENT ABOVE