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HIPAA Privacy Notice

Contact American Public Life Insurance Company

If you would like more information from APL, please complete and send the form below. We are committed to your privacy and understand the importance of protecting your personal information. Please see our privacy policy for more information.

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Your Information

* First Name	* Last Name
* E-mail Address	* Telephone Number	Ext.

*Address Line 1

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* City

* State

* Zip Code

Are you a current APL customer?
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Does your employer offer APL
products at work?
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Additional Comments:

Which products interest you?

The following products are available for sale to individuals. Please note that not all products are available in all states.

    Individual Accident Only Insurance
    Individual Hospital Indemnity Insurance
    Individual Dental Insurance
    Intensive Care/Coronary Care Insurance
    Individual Cancer Expense Insurance
    Heart Disease/Heart Attack/Stroke Insurance
    Health Savings Accounts
    Childrens's Life Insurance

How did you hear about American Public Life?

These products may contain limitations, exclusions and waiting periods. Please contact us for complete details regarding any of these products, including specific state brochures.

APESB-355

Last Updated: Thursday August 20 2009

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	® American Public Life is a Registered Trademark