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, who is a member of OPEIU Local 277, will call on you to deliver your certificate of coverage, witness your beneficiary designation, register you for the AIL Plus program and provide your Child Safe Kits. 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.