Form Bn-658(Ca)-0307 - Group Disability Claim Page 2
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4American Fidelity Assurance Company
Mail to:
AFES Benefits Department
P.O. Box 25160
Oklahoma City, OK 73125-0160
Toll Free Phone # 1-800-662-1113
Toll Free Fax # 1-800-818-3453
EMPLoYEr’S rEPorT oF CLAIM
Name of Employer:
Phone No.:
(
)
Mailing Address: (include street, city, state and zip code)
Fax No.:
(
)
Name of Employee:
Social Security Number:
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Address: (include street, city, state and zip code)
Phone No.:
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(
)
o
Y
Date of Hire:
Effective date of employee’s coverage:
Occupation: (please attach job description)
M
E
N
Status of employment at time of disability:
o Full-Time
o Part-Time
o Leave of Absence
o Terminated
o Retired
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Number of hours worked per week at time of disability:______________________
Inhouse days:
First Day ________________
Number of contract days: _______________________ for ____________ school year.
Last Day ________________
Has employee’s status of employment changed? o Yes o No If yes, current status and date of status-change? __________________
Does employee participate in Social Security?
o Yes
o No
If no, hired after 4/1/86?
o Yes
o No
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r
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Please furnish the percentage of the employee’s AFA disability premium you pay: ________________% Short Term ______________
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Long Term ______________
Are the AFA disability premiums withheld before or after taxes?
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Short Term Plan o Before o After Long Term Plan o Before o After
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CoNTrACTED SALArY AT TIME oF DISABILITY
S
A
Monthly: $_____________________ Effective Date: _________________________ o 9 o 10 o 12 Month Work Schedule
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A
Annual: $ _____________________ Effective Date: _________________________ o 9 o 10 o 12 Month Work Schedule
r
Y
Date employee last worked:_______________________________
Have AFA Disability premiums been withheld
D
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Has employee returned to work?
o Yes
o No
through the last date worked? ______________
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B
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If not, what is the last date disability premiums
If Yes, date returned to work:
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were deducted? _________________________
Full Time: __________________________
Part Time: ________________________
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Did Employee’s disability result from employment?
o Yes
o No
If yes, name, address and phone number of Worker’s Compensation carrier: _______________________________________________________
o
Has employee made a claim for or entitled to Worker’s Compensation?
o Yes
o No
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H
If yes, weekly rate of compensation: $
E
r
Provide:
The final date the employee is entitled to fully paid sick leave __________________________________________________________
The first date the employee is entitled to differential/sabbatical pay, if any _______________________________________________ _
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N
The last date the employee is entitled to differential/sabbatical pay ___________________________________________________ __
C
o
The daily rate of differential/sabbatical pay $ _____________________________________________________ __________________
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Name, address and phone number of any other disability carrier: (include street, city, state and zip code)
Is employee eligible for disability retirement benefits?
o Yes
o No
remember - To attach a copy of the applicable school calendar for any contracted employee.
FAILUrE To Do So CoULD rESULT IN DELAYED BENEFITS
I hereby certify that the above named employee is a member of our Group Disability Program. The Information stated above is correct to the best of my
knowledge and belief.
Authorized signature of employer firm or authorized official: _________________________________________________________________________
Title: ______________________________________________________ Date: ________________________________________________________
E-mail Address:____________________________________________________________________________________________________________
BN-658(CA)-0307
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