American Income Life
Insurance Co.
PO Box 50158  Indianapolis, IN  46250
 
Group Accident & Sickness Insurance

Available to Coop Extension Service & related Groups 
as approved by American Income Life.  

Hit Counter  =  "SERIAL NUMBER" 

Todays Date

I would like to request the following coverage:

Plan # 1 (.15 per person per day)

Plan # 2 (.20 per person per day)

Plan # 3 (.23 per person per day)

Date Insurance to be placed in force

Number of People to be insured

Number of Days

Name of Group

What is the Activity?

Leader Name

Title

Address

City/State/Zip

County

Phone

E-mail address 

Need Forms?

Serial Number:   (from HIT COUNTER number below)

PLEASE NOTE -- There is a $4.00 minimum premium per event.

*Upon hitting the "Submit" button, an immediate confirmation page will be displayed. Please print a copy and retain for your records. This may also be used to send in with your payment. Payment address is PO Box 50158 Indianapolis, IN 46250 *
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Issued Under 
MASTER POLICY NO. 717
on file with the Director of Extension Service
PURDUE UNIVERSITY, LAFAYETTE, INDIANA,
as trustee for all Insured Members and Adult Leaders
in the United States and its Possessions.