Form Bn-658(Ca)-0307 - Group Disability Claim (Page 3 of 4) in pdf

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

EMPLoYEE’S DISABILITY BENEFITS APPLICATIoN

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

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

Full Name: (last, first, middle initial)

Maiden Name

Account Number:

Residence: (street, city, state and zip code)

Social Security Number:

Mailing Address: (P.O. Box or street, city and zip code)

Date of Birth:

Telephone Number: (including area code)

r Single

r Married

r Widowed

r Divorced

(

)

Occupation:

Has your employment terminated?

If so, date:

Names & birth dates of

_____________________________/_____/_____

Name

Birth date

Name

Birth date

spouse & dependents:

_____________________________/_____/_____

Name

Birth date

Name

Birth date

1. Date accident or illness began:

2. If accident, explain where and how it happened?

3. Have you ever had the same or similar condition in the past? r Yes r No

If yes, names and address of treating physicians and/or hospitals:

4. Nature of illness or injury:

5. Dates of medical treatment:

Date of next Doctors appointment:

6. If hospitalized give full name(s) and addresses

of hospitals: (attach additional list if necessary)

Admit Date: _______/_______/_______ Discharge Date: _______/_______/_______

7. Full names and addresses of all treating physicians:

8. Is your disability related to your employment/occupation? r Yes r No

(attach additional list if necessary)

If yes, have you or do you intend to file for Worker’s Compensation?r Yes r No

9. On what date did you last work?______________

Dates of total disability: From ______________

Thru ________________

On what date did you return to work?

Part Time ________/________/________

Full Time ________/________/________

If not returned to work, when do you anticipate returning to work?___________________________

10. If your request for benefits is approved do you want us to withhold Federal Taxes from each benefit check? r Yes

r No

If yes, amount: $ _______________________ (indicate amount per month $86.00 minimum)

11. Identify other income sources and amount of income for which you are receiving or may be entitled to receive during this disability

Your Social Security: (disability or retirement) r Yes

r No

$_______Mo.

V.A. Benefits:

r Yes

r No

$_______Mo.

Dependent Social Security:

r Yes

r No

$_______Mo.

Worker’s Compensation:

r Yes

r No

$_______Mo.

Sick Leave or Wage Continuation:

r Yes

r No

$_______Mo.

Other Disability Coverage:

r Yes

r No

$_______Mo

Retirement: (normal early or disability)

r Yes

r No

$_______Mo.

(identify)_____________________________________________

State Disability Income

r Yes

r No

$_______Mo.

Include a copy of your award or denial letter for any

source in which one has been received.

Signature: ____________________________________________________ Date: ____________________________________________________

I certify this information is true and correct.

AUTHorIZATIoN To DISCLoSE ProTECTED HEALTH INForMATIoN

I hereby authorize the entities specified below to disclose any information about my entire medical record or benefits payable for their disability and history of treatment for physical and/or emotional

illness to include psychological testing, except psychotherapy notes, to individuals representing American Fidelity Assurance Company (AFAC) who are involved in determining whether I am eligible

for benefits under my insurance coverage. Those so authorized are: a) licensed physicians or medical practitioners; b) hospitals, clinics or medically-related facilities; c) health plans; d) Veteran’s

Administration; e) past or present employers; f) pharmacy; g) insurance companies; h) the Social Security Administration; i) retirement systems; j) Department of Motor Vehicles; and k) Workers’

Compensation Carrier.

NoTICE: Information authorized for release may include information on communicable or venereal diseases such as hepatitis, syphilis, gonorrhea, HIV/AIDS (Human Immunodeficiency Virus/Acquired

Immune Deficiency Syndrome) or other conditions for which you may have been treated. This authorization excludes disclosure of the result of a test for HIV if you have tested HIV positive but have not

developed symptoms of the disease AIDS. Such test results shall not be discovered or published. Nothing in this caveat will prohibit this authorization from including the fact that you have AIDS.

I understand that I may refuse to sign this authorization; however, if I do not sign the authorization, my failure to sign the authorization may result in a denial or a delay of benefits.

I understand that I may revoke this authorization at any time by writing to AFES Benefits Department, PO Box 25160, Oklahoma City, OK 73125-0160 or by calling, toll-free, 1-800-662-1113.

I understand that my right to revoke this authorization is limited to the extent that: AFAC has taken action in reliance on the authorization; or, the law provides AFAC with the right to contest my

insurance coverage or a claim under my insurance coverage. A copy of this authorization will be as valid as the original.

I understand that if protected health information is disclosed to a person or organization that is not required to comply with federal privacy regulations, the information may be redisclosed and no longer

protected by the federal privacy regulations.

For health insurance coverage this authorization will expire twenty-four months from the date it is signed or upon termination of my insurance policy, whichever occurs first. For insurance coverage other

than health insurance, this authorization will expire twenty-four months from the date it is signed or upon expiration of my claim for benefits, whichever occurs first.

_______________________________________________________________

______________________________________________

Signature (Patient) or Personal Representative (if applicable)

Printed Name (Patient)

_____________________________________________________________

______________________________________________

Relationship of Personal Representative to Patient

Date

If authorization is supplied by a personal representative a description of the authority to act on behalf of the Insured must be included.

Please retain a copy for your personal records, or you may request a copy from our company.