AAUP-Approved Insurance Plans Information Request Form Please mail my FREE Information Packet(s) on the following AAUP-approved plans:
LIFE AND HEALTH Accident Insurance (06)       1-800-882-5521 Group Term Life (07)       1-800-882-5521 Disability Insurance (05)       1-800-882-5521 Hospital Income Plan (29)       1-800-882-5521 Excess Major Medical (01)       1-800-882-5521	LIABILITY Professional Liability (68)        1-800-686-1172 Chapter Liability (78)        1-800-686-1172
To request your free information packet on the plans listed below, please call the phone number beside the plan name.     Short Term Medical (60) Customized Major Medical (29) 1-877-886-0110 1-877-886-0110
Please fill in all information:
* FIRST NAME:
* LAST NAME:
* STREET ADDRESS:
STREET ADDRESS:
* CITY:
* STATE:	AA  AE  AK  AL  AP  AR  AZ  CA  CO  CT  DC  DE  FL  GA  HI  IA  ID  IL  IN  KS  KY  LA  MA  MD  ME  MI  MN  MO  MS  MT  NC  ND  NE  NH  NJ  NM  NV  NY  OH  OK  OR  PA  RI  SC  SD  TN  TX  UT  VA  VT  WA  WI  WV  WY
* ZIP CODE:	-
AAUP MEMBER   NUMBER:
E-MAIL ADDRESS:
PHONE NUMBER:	-
DATE OF BIRTH:	DAY   MONTH   YEAR
* Required information. Your request cannot be submitted unless all required information is completed. When you have completed all information requested above, submit your request and your Information packet(s) will be mailed to your address. Information packet(s) cannot be sent electronically. Packets include information on the costs, exclusions, limitations, and terms of coverage for each plan. Coverage may not be issued to residents in all states.   AAUP Home