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AAAD&DAPP9433(1) .pdf


Original filename: AAAD&DAPP9433(1).pdf
Title: American Amicable - ADD.pdf
Author: dhancock

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AMERICAN-AMICABLE LIFE INSURANCE COMPANY OF TEXAS
P.O. BOX 2549, WACO, TEXAS 76702-2549

APPLICATION FOR INDIVIDUAL ACCIDENTAL DEATH AND
DISMEMBERMENT INSURANCE

1. Proposed Insured_____________________________________________________________
(Þrst, middle, last name)

2. Address: Street________________________City________________State_____Zip_______
3. Phone (_______)____________________ E-mail Address__________________@_________
4. Age_________ 5. Date of Birth____________________ 6. SS#______________________
(mo. day yr.)

7. Occupation (Duties)___________________________________________________________
8. Primary BeneÞciary______________________________Relationship___________________
Address_______________________________________________________________________
Contingent BeneÞciary___________________________Relationship___________________
Address_______________________________________________________________________
9. Accidental Death BeneÞt Amount $___________________ Premium $_________________
10. Mode:

Payroll Deduction

Bi-Weekly Allotment

Bank Draft

Other

Signed at____________________________ Date of Application________________________
City

State

Agent_______________________________ No.:_______ _________________________________
Signature

Form No. AA9433

Signature of Proposed Insured


Document preview AAAD&DAPP9433(1).pdf - page 1/1

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