Form Bn-658-1007 - Group Disability Claim printable pdf download

Form Bn-658-1007 - Group Disability Claim

Group Disability Claim

Filing Instructions

(Not for use when filing for Physician’s Expense Benefits)

Disability Claim form is to be completed after you become disabled.

1. Complete Employee’s Disability Benefits Application in full.

2. Have the treating physician complete the Attending Physician’s Statement

and return to you.

3. Have your Employer complete the Employer’s Report of Claim.

4. Submit the completed:

A. Employee’s Disability Benefits Application

B. Employer’s Report of Claim

C. Attending Physician’s Statement

to the address below or submit via our toll-free fax @ 1-800-818-3453

5. 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.

Signature: ___________________________________________________________

notE: you must attach a voided check to begin direct deposit.

All portions of this form package must be completed to avoid undue delay in

processing claimant’s request for benefits. if you have any questions regarding

completion of this form please call:

Toll Free Phone # 1-800-662-1113

Local Phone # 405-523-5025

Educational Services Division

Benefits Department

P.O. Box 25160

Oklahoma City, Oklahoma 73125-0160

Form Bn-658-1007 - Group Disability Claim