American Pioneer Life
Insurance Company Enrollment Form
Social Security No.
Last Name First
Initial
Birthdate
__M
__F
Home Address:
Street
Home Phone:
City State
Zip
LIST ALL DEPENDENTS TO BE COVERED BELOW
Last Name (if
different)
First
Name
Initial
Birthdate
Sex
2. Spouse
3. Dependent
4.
5.
6.
7.
Question: 1) Are all dependent children applicants
between the ages of 19 & 25 full-time students (Y/N) If no,
then which child(ren) are not full-time
students?_______________________________________
MODE OF PAYMENT:
__Annually
__Quarterly
__Monthly (by Bankdraft Only)
__Bankdraft This is authorization to draft payments from my
checking account. A voided check is enclosed on the
bank
for which the drafts are to be drawn.
OR
Charge Premiums to:
__Visa __ Mastercard
Credit card Number: _________________________
Exp. Date ____/____
"I understand and agree that (1) the insurance shall
not take effect unless the application has been accepted and
approved by the Company and until the Effective Date of the
Certificate and (2) the agent does not have the authority to make or
alter any contract or waive any of the Company's other rights or
requirements."
For a Full list of Exclusions & Limitations please
call:
Toll Free: 1-800-654-2010 ext. 218
or local Ocala, Florida residents may
call: 352-624-2100 ext 218