Your Information

* Please fill out all required fields

* First Name: Middle Initial: * Last Name: Date of Birth
(mm/dd/yyyy): Preferred Language:

Contact Information

Home Phone: Cell Phone: E-mail:

Address

* Street Address: *City: *State/Province: * Zip/Postal Code:

Other Information

Beneficiary: Beneficiary Date of Birth
(mm/dd/yyyy): Relationship: Number of Child I.D. Kits :

An AIL representative, who is a member of OPEIU 277, will provide your personalized certificate of coverage and witness your beneficiary designation, register you for the AIL Plus program and provide your Child Safe Kits. AIL has other supplemental insurance programs available.

Questions? Call AIL at 1-800-495-1213.