American Income Life
 
Insurance Co.

APPLICATION FOR  
BLANKET GROUP ACCIDENT INSURANCE

Name of Organization_________________________________

List Projects ________________________________________

Name of Leader _____________________________________

Mailing Address _____________________________________

City _________________________County  _______________

State _____________________Zip  ______________________

Email address:  ______________________________________

 

Desired Effective Date  ____________ Phone # ___________

Has this group had one of our annual policies within the last year?  

                    Yes             No  

Number of Regular Members Registered _____ X $1.00  (all members must be insured)
Number of Regular Leaders Registered _____   X $1.00 
(Shooting Sports / Livestock / Non-League Sports = $1.00)

Number of Horse Members Registered  _____  X $2.00

Number of Horse Leaders Registered   _____   X $2.00 
(Athletic League Sports / ATV / Motorcycle = $2.00)

 

Are Leaders to be Covered?              Yes           No

 

Covered Leaders Names:   

1.  ___________________________________________

2.  ___________________________________________

3.  ___________________________________________

4.  ___________________________________________ 

 

As authorized leader of the above group I request that a Master policy be 

issued on the effective date requested, or on the date this application is

received, whichever is later.  

 

We are attaching a check or money order payable to the American Income 

Life Insurance Company, P.O. Box 50158, Indianapolis, Indiana 46250, 

calculated at the rate  of  $1.00 for each person  ($2.00 horse/other)

. 

MINIMUM PREMIUM PER POLICY - $10.00.  

 

Signed ___________________________________________

                            Authorized Group Leader

Print this form and MAIL with your premium check 

TO:   American Income Life Insurance Company   

P.O. Box 50158 · Indianapolis, IN 46250

(317) 849-5545 or 1-(800) 849-4820  

Policy Number _______________(Assigned by A.I.L.)

Issue Date __________________(Assigned by A.I.L.)

 

Note:  Coverage begins automatically one day after your 

application and check have been postmarked.

 

Application 103-86