Physical description

Blue coupon, dated Sep 8 1875, asking Mr. W. Philpot, Treasurer, to pay Insurance the sum of £1/5/- for No. 1 Mo? Signed by G. Marcay, Acting C.R. and W. B. Evans?, Secretary. Also signed across the coupon by W. B. Evans. Note written on the side: Paid to Mr. Hallam, W. Hu?