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American Income Life Policy 5063s Coverage Request Form

Existing policyholders can submit an activity report here. Fill in all required forms (required forms are marked with an asterisk*) and describe your activity in the Activity Description box. Type in the start date, the estimated number of people in your group, the number of days you’ll need coverage, and select your rate. When the form is filled out, click ‘Submit’.

*Required
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Policy Number

Organization*

Leader First Name*

Leader Last Name*

Group Name*

Phone Number*

Email*

Address*

City*

State*

ZIP*

Comments
(If event dates are not consecutive please list all dates below.)


At least one activity must be filled out below. You may fill out up to 10 activities per submission.

Activity Description Start Date End Date # of Daily Participants # of Days Rate

($X.XX)

Table of Benefits

Policy SRP 106

Plan A
24¢ person/day
covers up to:
Plan B
30¢ person/day
covers up to:
Day Plan C
12¢ person/day
covers up to:
Plan D
40¢ person/day
covers up to:
  • Medical / surgical treatment
  • X-ray examinations
  • Hospital confinement
  • Ambulance expense
  • (within 52 weeks of accident)

$2,500 $3,000 $2,500 $1,500
    Dental services

    (incurred within 52 weeks of accident)
$300 $500 $300 $300
    Medical and hospital expense

    (for Illness while policy in force)
$750 $1,000 None $500
  • Poliomyelitis
  • Diphtheria
  • Scarlet Fever
  • Smallpox
  • Tetanus
  • Cerebrospinal Meningitis
  • Typhoid Fever
  • Leukemia
  • Primary Encephalitis
$2,500 $3,000 None $2,000
    Loss of life

    (within 100 days of resulting accident)
$2,500 $3,000 $2,500 $2,000
Loss of

  • Both hands
  • Both feet
  • Total sight of both eyes
  • One hand and one foot
  • (within 100 days of accident)

$7,500 $7,500 $2,500 $3,000
Loss of

  • One hand
  • One foot
  • Sight of one eye
  • (within 100 days of accident)

$3,750 $7,500 $1,250 $1,500

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Only hit submit button once to avoid submitting duplicate request of coverage.