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


ELECTRONIC SIGNATURE AUTHORIZATION
AMERICAN INCOME LIFE NEW BUSINESS APPLICATION



DATE:

APPLICANT LAST NAME:

APPLICANT FIRST NAME:

OWNER'S NAME:

AGENT NAME:

AGENT NUMBER:	

With reference to my application for insurance coverage with American Income Life Insurance 
Company (“American Income Life”) on this date, I, the above-referenced applicant (the 
“Applicant”), hereby authorize the above-referenced American Income Life agent (the “Agent”) 
to affix my electronic signature to the application and any attendant documentation requiring 
my signature (collectively, the “Application”) and to submit the Application to American 
Income Life for underwriting. 

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 hereby evidence 
        my intent to apply for insurance coverage with American Income Life;

•	I agree that this Application may be signed electronically in each instance in which 
        my signature is required;

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

•	I agree that the Agent may electronically submit the completed and signed Application 
        to American Income Life for review and processing.

This authorization pertains only to the Application and will be used for no other purpose 
than contemplated herein. The electronic signature referenced in this authorization will be 
encrypted and will pertain only to the Application. The electronic documents maintained by 
American Income Life are the sole original versions of those documents. American Income Life 
maintains physical, electronic and procedural safeguards to protect all nonpublic personal 
information from unauthorized use or improper access.