American Life & Security Corp.
Executive Office P.O. Box 5577 • LINCOLN NE 68505-­‐5577 Phone: 402.489.8266 • Fax: 402.489.8295 REQUEST FOR REDUCED PAID UP OPTION I request the Reduced Paid Up Option on the following: Policy Number: POLICY NUMBER 1 POLICY NUMBER 2 POLICY NUMBER 3 POLICY NUMBER 4 Insured’s Full Name: __________________________________________________________________ X_______________________________________________ Owner’s Name (printed) ________________________________________________ __________ Owner’s email address Date: _________________________________________ X______________________________________________ Owner’s Signature (Always Required) __(_______)_______________________________________________ Owner-­‐Day time phone: ___Home ___Cell ___Work X______________________________________________ X______________________________________________ Co-­‐Owner’s Name (printed) Co-­‐Owner’s Signature (Required if Co-­‐Owner exists) _________________________________________________________________ Co-­‐Owner’s email address AL – RPU 10/11 __(_________)___________________________________________________ Co-­‐Owner-­‐Day time Phone: ___Home ___Cell ___Work