Discount Medical Plan Application for American Income Partners ™ Basic Program
Please Note: This plan is not available for New York

First Name    
Middle Initial  
Last Name    
Age  
Sex 
Marital Status   
Social Security Number # eg. 111223333 (no dashes or spaces)
 
Mailing Address    
Address Line 2  
City    
State
Zip 10 digit zip/postal code    
Residence Phone eg. 1112223333    
Email  
Referring Group/Member of  
Allow 10-14 business days to receive your membership card in the mail. Administered by Coverdell & Company, Inc., a discount medical plan organization at 8700 W. Bryn Mawr, Suite 1000, Chicago, IL 60631, 1-800-308-0374.
AILAPP-02 (R0907)American Income Partners is not insurance.