Your Information

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

Contact Information

Home Phone: Cell Phone:

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 will call on you to deliver your certificate of coverage, witness your beneficiary designation and provide your other no-cost items. AIL has other supplemental insurance programs, presented in the spirit of “Be Union – Buy Union,” available strictly on a voluntary basis.

If you have questions, please call American Income Life Insurance Company at 1-800-495-1213.