1.	Please click Reply All to your agent and AILMods@ailife.com 
2.	Type the word “Agree” at the top of this email
3.	Click Send


SIGNATURE AUTHORIZATION
AMERICAN INCOME LIFE MODIFICATION OR AMENDMENT TO COVERAGE REQUESTED



DATE:

APPLICANT LAST NAME:

APPLICANT FIRST NAME:

OWNER'S NAME:

AGENT NAME:

AGENT NUMBER:	

POLICY NUMBER: 

MODIFICATION OR AMENDMENT SUMMARY:   


With reference to my application for insurance coverage with American Income Life Insurance Company
(“American Income Life”) and the Modification or Amendment which was explained to me by the agent on 
this date, I, the above-referenced applicant (the “Applicant”), hereby authorize the above-referenced 
American Income Life agent (the “Agent”) to affix my signature to the Modification or Amendment of
coverage initially applied for and to submit the Modification or Amendment to American Income Life 
to acknowledge my acceptance of those changes. 

I understand that by responding “Agree” to this email, I am affirmatively stating that:

•	I agree to the terms and conditions set forth in the Application and Modification or Amendment
	and hereby evidence my intent to apply for insurance coverage with American Income Life;

•	I agree that the Agent may sign the Modification or Amendment on my behalf in each instance in 
        which my signature is required, and that such signature shall have the same effect as 
        if I had signed the Modification or Amendment by hand; and

•	I agree that the Agent may submit the completed and signed Modification or Amendment to American 
        Income Life for review and processing.

This authorization pertains only to the Modification or Amendment to the original Application for insurance
and will be used for no other purpose than contemplated herein. American Income Life maintains physical, electronic
and procedural safeguards to protect all nonpublic personal information from unauthorized use or improper 
access.