Membership Request Form

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Membership Request Form

To receive a personalized quote and application for AAFMAA life insurance by mail, please provide the following. Your information will be kept confidential.

1. Personal Information

First Name:

Last Name:

Date of Birth:

Gender:

Street Address:

Street Address 2:

City:

State:

Zip:

Home Phone:

(ex: (123) 456-7890)

Work Phone:

(ex: (123) 456-7890)

Fax:

(ex: (123) 456-7890)

E-Mail:

2. Additional Information

Service:

Status:

Rank:

Have you used nicotine products in the last 12 months?

3. For a personalized application for your spouse also, provide the following:

Spouse First Name:

Spouse Last Name:

Spouse Date Of Birth:

Spouse Nicotine Use:
(in last 12 months)

4. Please send me information on:

Term Life Insurance:

Value-Added Whole Life Insurance:

Include a FREE Life Insurance Buyers Guide:

How did you hear about AAFMAA?

Please include any other comments below.

If you have any other questions, comments, or changes, please e-mail them to info@aafmaa.com.

	Get an ONLINE instant quote or request an application

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