Form Bn-708 - Request For Testing Benefits - American Fidelity

ATTN: AFES BENEFITS DEPT.

P.O. Box 25160

Request foR

Oklahoma City, Oklahoma 73125

Toll Free: 1-800-662-1113

testing Benefits

Fax: 1-800-818-3453

INSTRUCTION TO INSURED

1. Complete STATEMENT OF INSURED.

2. this form is only to be used for Cancer Diagnostic Benefit, Accident only Wellness Benefit, and Critical illness Health screening Benefit.

Please mark all that apply.

3. Please attach bill, receipt, or evidence of the test. submitted evidence must include the name of the test and the date of service.

4. Be sure to include your account number or Social Security number on all documents.

5. fax or mail the completed claim form.

STATEMENT OF INSURED

1. insuReD fuLL nAMe_______________________________________________________________ Account no. ______________________

(Please Print)

(Last)

(first)

(M.i)

Date of Birth _____/_____/_____

insured social sec. # __________-_______-__________ telephone # ___________________

(Mo)

(Day)

(YR)

2. Address ____________________________________________________________________________________________________________

(street)

(City)

(state)

(Zip Code)

3. if claim is for dependent, give name of dependent________________________________________ Relationship_________________________

Date of Birth _____/_____/_____

(Mo)

(Day)

(YR)

o Cancer Diagnostic Benefit

o Accident only Wellness Benefit

o Critical illness Health screening Benefit

DIRECT DEPOSIT AUTHORIzATION

Please complete if you desire benefits deposited directly into your bank account.

i authorize AfAC to initiate credit entries to my account at the depository named below. this authorization is to remain in force and effect until AfAC

receives written notification from me of its termination in such time and in such manner as to afford AfAC and the Depository opportunity to act on it.

This authorization applies to benefits payable under all insurance policies held with AFAC.

signature: ________________________________________________________________________________________________

NOTE: You must attach a voided check to begin direct deposit.

Warning: Any person who knowingly and with intent to injure, defraud, or deceive an insurer files a statement of claim containing any false, incomplete, or misleading

information may be guilty of insurance fraud and subject to criminal and civil penalties.

California - For your protection, California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent claim for the

payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

AR, DC, LA, MD, NJ, NM, TX, and WV - AnY PeRson WHo KnoWingLY PResents A fALse oR fRAuDuLent CLAiM foR PAYMent of A Loss oR Benefit

oR KnoWingLY PResents fALse infoRMAtion in An APPLiCAtion foR insuRAnCe is guiLtY of A CRiMe AnD MAY Be suBJeCt to fines AnD

ConfineMent in PRison.

DE, ID, IN, MN, OH, and OK - WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any

false, incomplete, or misleading information is guilty of a felony.

Colorado - it is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting

to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company

who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the

policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the

department of regulatory agencies.

New Hampshire - Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or

misleading information is subject to prosecution and punishment for insurance fraud, as provided in RsA 638:20.

Kentucky - Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false

information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Oregon - Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application, or (2) by filing a claim containing

a false statement as to any material fact, may be guilty of insurance fraud.

Pennsylvania - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim

containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,

which is a crime and subjects such person to criminal and civil penalties.

Arizona - for your protection, Arizona law requires the following statement to appear on this form: Any person who knowingly

presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Florida - Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or

misleading information is guilty of a felony of the third degree.

Hawaii - For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime

punishable by fines or imprisonment, or both.

Bn-708(Afes)