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
