American Income Life Insurance Co.

You must be a current policyholder to complete the application card below.

Hit Counter = Serial Number (requested below)

Activity APPLICATION Card for
Group Accident & Sickness Insurance (must be e-mailed to us before your event begins)

I would like to request the following insurance for my group: 

Serial Number: (from Hit Counter ABOVE)                                              Policy Number:     

Number of People to be insured     Number of Days   Rate per day?

Event Dates   What is the Activity?   

Name of Group   

 Leader Name Organization

Address  

City/State/Zip

Phone     E-mail address  

Need Forms?               Upon hitting the Submit Button, a confirmation page will be displayed.  Please retain for your records.  You may also use it to send with your payment after your activity has concluded.  Payment address is:  PO Box 50158 Indianapolis, IN  46250                                           Policy Number SRP 106 REV 3-81